allergies: no known allergies / adverse drug reactions attending: chief complaint: elevated creatinine major surgical or invasive procedure: intubation and transfer to icu, paracentesis history of present illness: this is a 65 year old male with pmh of alcohol-related cirrhosis complicated by esophageal varices, h/o portal vein thrombosis, refractory ascites s/p tips which is stenosed, h/o hepato-renal syndrome requiring admission to from to , and h/o sbp on bactrim ppx, dm, pituitary mass, and hypothyroidism with recent admission to in for hepatic encephalopathy who presents today with a creatinine of 3.5 from 2.6 prior (baseline mid 2s) from daycare clinic after a 6.75l paracentesis. the patient's wife reports that mr. has had increased fatigue recently, but denies any confusion. no sick contacts and reports good adherance with all medications including lactulose regimen. . in daycare, he had a paracentesis which removed 6.75l of ascitic fluid, with a sample sent to rule out sbp. he received 62.5g of albumin, vitals were stable: bp 161/75, hr 64, sat 99% on ra. labs were significant for a hct of 28, creatinine of 3.5, negative etoh. . review of sytems: patient denies cp, palp, sob, recent uri sx, cough, fever, n/v/d. no change in appetite, dysuria or change in stool. otherwise as per hpi. past medical history: alcoholic cirrhosis known varices portal vein thrombosis s/p tips dm hypothyroid pituitary mass h/o nephrolithiasis h/o +ppd social history: lives w/ wife at home. independent in adls and ambulation. smokes cigars per day. no alcohol for the last 5 months. denies ivdu. no etoh since . family history: mother deceased, age 50, cva. father deceased, age 62, stomach problems. one brother living and in good health. two sisters, both living and in good health physical exam: on admission: vitals: 98.1 133/49 53 20 100%ra general: appears fatigues, lying in bed. heent: perrla, eomi, anicteric, mmm, op clear neck: supple, no jvd or lad heart: rrr, s1 and s2 appreciated, no m/r/g lungs: ctab abdomen: soft, nt. moderately distended. lvp site without bleeding and covered by bandage. extremities: 1+ edema in le, 2+ pulses neurological: fatigued. a&ox3. cn ii-xii grossly intact. discharge: vitals:temp 98.2(98.2) 125-157/63-70 -78-20-100%ra. i/o: 0 + 100/475 + 4 stool 24hrs: 1220++ 17bm general: nad. somnolent. heent: mmm, perrl. cardiac: rrr, 1/6 systolic ejection murmur. lungs: clear but lll with decreased bs abdomen: soft but distended with ascites worsening distention, bs present extremities: pedal edema +1. no asterixis pertinent results: labs on admission: 08:10am blood wbc-4.2 rbc-3.13* hgb-9.8* hct-28.5* mcv-91 mch-31.4 mchc-34.5 rdw-16.0* plt ct-123* 08:10am blood pt-15.4* inr(pt)-1.3* 08:10am blood glucose-183* urean-57* creat-3.5* na-140 k-4.7 cl-111* hco3-18* angap-16 06:00am blood alt-21 ast-40 ld(ldh)-178 alkphos-222* totbili-0.3 04:33am blood wbc-5.7# rbc-2.84* hgb-9.0* hct-25.3* mcv-89 mch-31.5 mchc-35.4* rdw-15.6* plt ct-123* 08:31am blood wbc-6.5 rbc-3.06* hgb-9.7* hct-27.8* mcv-91 mch-31.9 mchc-35.1* rdw-15.7* plt ct-149* 08:00pm blood wbc-6.7 rbc-2.89* hgb-9.2* hct-26.1* mcv-90 mch-32.0 mchc-35.4* rdw-15.7* plt ct-109* labs on discharge: 05:30am blood wbc-5.2 rbc-2.81* hgb-8.9* hct-25.9* mcv-92 mch-31.5 mchc-34.2 rdw-18.7* plt ct-106* 05:45am blood wbc-4.5 rbc-2.66* hgb-8.4* hct-24.8* mcv-93 mch-31.5 mchc-33.8 rdw-18.8* plt ct-110* 05:50am blood wbc-4.1 rbc-2.63* hgb-8.3* hct-23.6* mcv-90 mch-31.7 mchc-35.4* rdw-18.7* plt ct-98* 05:50am blood pt-16.1* ptt-30.5 inr(pt)-1.4* 05:50am blood plt smr-low plt ct-98* 06:00am blood glucose-143* urean-57* creat-3.2* na-140 k-4.5 cl-111* hco3-19* angap-15 04:24pm blood glucose-216* urean-92* creat-5.2* na-145 k-3.6 cl-112* hco3-19* angap-18 04:39am blood glucose-146* urean-92* creat-5.0* na-149* k-3.4 cl-116* hco3-19* angap-17 07:00am blood glucose-250* urean-47* creat-2.6* na-143 k-3.8 cl-110* hco3-23 angap-14 05:50am blood glucose-198* urean-41* creat-2.6* na-141 k-3.7 cl-109* hco3-21* angap-15 04:33am blood alt-22 ast-41* ld(ldh)-186 alkphos-196* totbili-0.8 05:50am blood alt-21 ast-35 ld(ldh)-192 alkphos-178* totbili-1.3 liver u/s impression: 1. large differential between the peak systolic velocities of the proximal and distal segments of the tips consistent with known tips stenosis, though patency of the tips is maintained. 2. the left portal and anterior right portal veins are patent, however, directionality of flow cannot be assessed due to limitations of patient's respiratory rate and inability to comply with breath-hold. 3. stable moderate ascites. 4. cirrhotic liver. : chest ct: impression: 1. new small left pleural effusion. 2. stable appearance of peribronchial opacities in the left lower lobe may represent acute infection or sequela of aspiration. 3. stable multifocal bronchiectasis, likely due to recurrent infection. 4. large amount of ascites with cirrhotic liver. 5. atherosclerotic disease. . peritoneal fluid cytology: negative for malignant cells. . liver ultrasound: impression: 1. large differential between the peak systolic velocities of the proximal and distal segments of the tips consistent with known tips stenosis, though patency of the tips is maintained. 2. the left portal and anterior right portal veins are patent, however, directionality of flow cannot be assessed due to limitations of patient's respiratory rate and inability to comply with breath-hold. 3. stable moderate ascites. 4. cirrhotic liver. brief hospital course: mr. is a 65 year old male with pmh of alcohol-related cirrhosis complicated by esophageal varices, encephalopathy, h/o portal vein thrombosis, refractory ascites s/p tips on ltpx list who presented to following a cr of 3.5 following large volume paracentesis and concern for hrs. active issues: #. arf/hrs: the patient was seen in clinic for an lvp during which 6.5l of fluid were removed. labs drawn before the lvp revealed a cr of 3.5 up from patient's baseline of low 2s. immediate concern was for hrs and the patient was admitted. he was initially given an albumin challenge during which his cr dropped minimally to 3.2. he was started on midodrine/ocreotide on . patient's kidney function did not improve and midodrine/octreotide was stopped. creatinine than began to fall without intervention and patient was discharged with creatinine at baseline of 2.6. #. encephalopathy: the patient has a h/o etoh cirrhosis and was most recently admitted in early for mgmt of encephalopathy. at that time, the patient admitted to missing doses of lactulose and having <3 bms daily. on this asmission, the patient confirmed adherance to lactulose/rifaximin regimen and was not confused on admission. overnight on , the patient's wife reports that he became increasingly confused. an extra dose of lactulose was given and the patient had a bm. the following am, the patient was somnolent and could not be roused. triggered for nursing concern regaring ams. abg on ra showed po2 of 63 and the pt was satting in the low 90s. placed on nrb, cxr, ecg and suction performed. sicu consulted and patient was transferred for a brief stay until mental status improved with increased lactulose dosing. he returned to the floor with improved mental status and though had some day-to-day waxing and of mental status, was managed well on lactulose and rifaximin titrated to 3-4bm/day. ruq u/s showed stenotic, but patent tips and patency of the visualized portal vasculature. pts mental status remained stable and he took in adequate po intake. he was discharged on lactulose 60ml po q6hrs and rifaximin 550mg . 3. lll pneumonia/pleural effusion: patient completed a course of zosyn for lll pneumonia seen on . he showed interval improvement with less coughing, but worsening of an associated pleural effusion was seen on repeat cxr on in the setting of decreased breath sounds and increased coughing. he was re-started on vanc/zosyn emprically and chest ct showed resolution of pna. he completed a 8 day course of zosyn and pna had resolved by time of discharge. inactive/chronic issues: #. diabetes mellitus: the patient has a h/o dmii and is on a home regimen of 28 units glargine with humalog sliding scale. continued on hiss and 20 units glargine in house with good sugar control. #. hypothyroidism. the patient has a h/o hypothyroidisim. continued home regimen of levothyroxine 100mcg daily. transitional issues: please check daily weight encourage po intake, do calorie counts and please give sugar free carnation breakfast tid transfusion parameters: one u prbc if crit is under 23 and notify transfusion center please give pt lactulose 60ml po q6hrs and titrate up if not have >3 bm/day. can give prn at night if pt having >2bm/8hr medications on admission: 1. lactulose 10 gram/15 ml solution: 30ml po tid 2. levothyroxine 100 mcg tab: 1 tab po once a day. 3. propranolol 20 mg tab: 1 tab po twice a day. 4. magnesium oxide 400 mg tab: 1 tab po once a day. 5. calcium 500 500 mg calcium (1,250 mg) tab: 1 tab po once a day. 6. clotrimazole 10 mg troche: 1 troche qid 7. omeprazole 20 mg cap: 1 cap, po once a day 8. insulin glargine 100 unit/ml solution: 28 units sq hs 9. insulin lispro 100 unit/ml solution: per sliding scale sq qachs 10. ergocalciferol (vitamin d2) 50,000 unit cap: 1 cap po once a week. 11. bactrim 400-80 mg tablet: 1 tab po once a day. 12. midodrine 5 mg tablet: 3 tab po three times a day discharge medications: 1. lactulose 10 gram/15 ml syrup sig: sixty (60) ml po q6h (every 6 hours): if under three bm/24 hr titrate dose up until having at least three bm. 2. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day). 3. lactulose 10 gram/15 ml solution sig: 1000 (1000) mls po q12h (every 12 hours) as needed for hepatic encephalopathy. 4. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 5. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 7. heparin flush (10 units/ml) 1 ml iv prn line flush temporary central access-floor: flush with 10 ml normal saline followed by heparin as above daily and prn. 8. insulin glargine 100 unit/ml solution sig: twenty eight (28) units subcutaneous at bedtime. 9. insulin lispro 100 unit/ml solution sig: per sliding scale units subcutaneous qachs. 10. calcium 500 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po once a day. 11. magnesium oxide 400 mg tablet sig: one (1) tablet po once a day. 12. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 13. bactrim 400-80 mg tablet sig: one (1) tablet po once a day. 14. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a week. discharge disposition: extended care facility: hospital - discharge diagnosis: hepatorenal syndrome hepatic encephalopathy pneumonia discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , it was a pleasure taking care of you. you were admitted to the hospital because your kidneys began to fail. after close monitoring, your kidney function improved and currently they are working at their baseline function. you also had mental status changes during your admission secondary to your liver failure. we treated you with lactulose and you improved. finally, you were found to have a pneumonia and we have treated it with antibiotics. we have made the following changes to you medications. medications discontinued: propanolol medications changed: lactulose 30ml by mouth three times a day to 60ml by mouth every 6 hours. medications started: rifaximin 550mg tab take one tab twice a day spironolactone 50 mg tablet take one by mouth daily sevelamer carbonate 800mg take one tablet by mouth three times per day with meals followup instructions: you will need to follow up in the transplant clinic for a paracentesis and appointment. it will be on at 7:30 am at rcu ( of building at ). Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Venous catheterization for renal dialysis Percutaneous abdominal drainage Percutaneous abdominal drainage Diagnoses: Acidosis Hyperpotassemia Anemia of other chronic disease Tobacco use disorder Acute kidney failure with lesion of tubular necrosis Unspecified pleural effusion Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Alcoholic cirrhosis of liver Hepatorenal syndrome Other pulmonary insufficiency, not elsewhere classified Other and unspecified alcohol dependence, in remission Portal hypertension Unspecified acquired hypothyroidism Chronic kidney disease, unspecified Long-term (current) use of insulin Long-term (current) use of anticoagulants Other sequelae of chronic liver disease Other ascites Swelling, mass, or lump in head and neck Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Hepatic encephalopathy Portal vein thrombosis Esophageal varices without mention of bleeding