allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hyperkalemia, chest pain, ischemic colitis chronic renal insufficiency major surgical or invasive procedure: 1. exploratory laparotomy. 2. extensive lysis of adhesions. 3. repair of small bowel serosal injury. 4. right and left component ventral herniorrhaphy. history of present illness: 87 yo f with h/o chronic renal insuficiency, nephrectomy for renal cell carcinoma, and hypertensive nephrosclerosis who presents to the ed after being found in her doctor's office to be hyperkalemic. at the ed, ecg changes consistent with hyperkalemia were found. . patient reported history through mother and phone interpreter. she has not been feeling well for a while now, with chest pain, fatigue and sob. these symptoms have been present for many months, but the cp and sob have been more severe over the last couple days. two days ago she started experiencing a squeezing, pressure pain on the left side of the chest and left shoulder, which at times radiated down the left arm. the pain occurs at rest and nothing, except for nitroglycerin, improves or resolve this pain. this episode she had two weeks ago lasted for about two hours. pt took nitro, which decreased the pain but did not resolve it completely. after two hours the pain resolved on its own. she is not experiencing cp, sob now. . in the ed, vs were t 97.1, hr 64, bp 192/48, rr 16, o2sat 98%. k was 6.6 on admission to ed. she was given calcuim gluconate, sodium bicarbonate, dextrose, insulin, kayexelate 30 g. at time of admission to the medicine service her k was 5.3. . ros: ms. has had a 20 pound weight loss over the last 6 months because of loss of appetite. she mostly drinks tea during the day. she has had chronic abdominal pain not related to eating, last colonoscopy in . denied nausea, vomiting, hematochezia, orthopnea, pnd. has had bilateral leg swelling for many years, but no pain or worsening edema now. past medical history: 1. diabetes 2. htn 3. hypercholesterolemia 4. arthritis 5. hypothyroid 6. s/p nephrectomy for renal cell ca done in 94 at bu 7. mregurgitation 8. chronic abdominal pain 9. h/o pancreatitis 10. pancreas divisum 11. hiatal hernia repair 12. left colectomy b 2 colon cancer with neg nodes 13. ccy social history: no tob, no etoh, no narcotics, lives by self in family history: nc physical exam: vs: hr 64 bp 181/87 rr 16 o2 sat 99% gen: nad heent: perrla, eomi, sclera anicteric, op clear, mmm, no lad, bilateral carotid bruits. no jvd. cv: regular, nl s1, s2, holosystolic murmur on lsb chest: no pain with palpation pulm: cta bl, no r/r/w. abd: soft, tender throughout more on the llq, nd, + bs, no hsm. ext: warm, 1+ dp/radial pulses bl, edema up to the knees bilaterally. neuro: alert & oriented x 3, cn ii-xii grossly intact. pertinent results: 03:00pm blood wbc-4.5 rbc-2.70* hgb-8.5* hct-27.3* mcv-101*# mch-31.6 mchc-31.3 rdw-14.8 plt ct-148* 09:11pm blood wbc-12.0*# rbc-2.50* hgb-7.7* hct-24.3* mcv-97 mch-30.9 mchc-31.7 rdw-14.9 plt ct-134* 03:00pm blood urean-37* creat-1.7* na-144 k-6.3* cl-116* hco3-17* angap-17 09:30pm blood glucose-123* urean-34* creat-1.9* na-143 k-4.2 cl-119* hco3-17* angap-11 02:05am blood glucose-120* urean-71* creat-3.2* na-141 k-3.8 cl-111* hco3-20* angap-14 03:00pm blood alt-13 ast-16 alkphos-46 totbili-0.2 dirbili-0.1 indbili-0.1 07:35am blood lipase-44 04:30pm blood lipase-50 06:33pm blood ck-mb-notdone ctropnt-0.02* 03:00pm blood totprot-6.0* albumin-3.6 globuln-2.4 calcium-7.9* cholest-116 02:05am blood calcium-7.0* phos-4.7* mg-2.2 03:00pm blood %hba1c-5.5 . ct abdomen w/contrast 1:20 pm impression: free fluid and large amount of fat stranding seen within the abdomen, particularly in the region of the splenic flexure. relative narrowing of the sma. findings are concerning for ischemic colitis. 2) no evidence of obstruction or intra-abdominal mass. 3) status post left nephrectomy. multiple small rounded low attenuation lesions seen within the right kidney, possibly representing cysts but incompletely characterized on this single-phase study. . portable abdomen 7:31 am impression: 1. unchanged appearance of the multiple massively dilated loops of large bowel. 2. unusual appearance of a loop of bowel projecting within the mid pelvis, probably air filled small bowel--continued followup advised. . dr. . /kg diagnosis: fibroadipose tissue and mesothelium with reactive changes, consistent with hernial sac. . renal u.s. port 12:22 am impression: mild prominence of the collecting system suggestive of a very mild hydronephrosis. probable non-obstructive 4 mm right upper pole renal calculi. . chest (portable ap) 4:20 pm impression: 1. low position of endotracheal tube as communicated to dr. . 2. left lower lobe atelectasis. brief hospital course: a/p: 87 yo f with h/o chronic renal insuficiency, nephrectomy for renal cell carcinoma, and hypertensive nephrosclerosis who presents with hyperkalemia and ecg changes. . . 1. hyperkalemia: pt's h/o of cri and hypertensive nephrosclerosis are most concerning for an etiology. she also has a history of mgus. pt has been eating poorly which would suggest a component of decreased effective circulating volume. given these conditions it is likely that decreased urinary potassium excretion (from all these separate causes) is the underlying process. it is unclear how compliant patient is with meds and this could be contributing as well. - give iv fluids - check k q6h; give kayexelate if k elevated - maintain on telemetry - reorder ecg - check spep, upep - to check for multiple myeloma - hold ace inhibitor - low k diet - nutrition consult . 2. cri: baseline creat 2.0, pt at baseline now. - iv fluids - check creat - renal consult was obtained . 3. hypertension: patient with history of poorly controlled hypertension. - will continue home bp meds, and uptitrate as tolerated. - hold acei . 4. chest pain: patient with episode of chest pain two days prior, with multiple rf including high cholesterol, dm2, age, hypertension. although pain resolved at this time, will check for cardiac origin. - will check ce - ekg shows no acute st-t changes - continue labetolol, aspirin. hold acei for now. - check lipid panel, a1c - check repeat echocardiogram . 5. weight loss: patient endorses recent 20# weight loss, and has history of colon cancer. overdue for colonoscopy. also noted to have abdominal pain, but without acute abdomen. - check lfts, amylase, lipase - needs outpatient colonoscopy - guaiac all stools. - nutrition consult as above . 6. anemia: baseline hct per records has been in low 30s. now at 28. might be anemia of chronic disease or secondary to malnutrition given reported poor po intake in last months. no obvious bleeding, but will like to check stool. - guiaic all stools - fe studies. . 7 hyperlipidemia: history of hyperlipidemia on record, but current lipid panel results were within normal levels . 8 chronic le edema: long time issue. stable now. no pain, erythema or skin color changes. chf a possibility and will be explored. - check echocardiogram for ef . 9 hypothyroid: stable condition - continue levothyroxine = = = = = = = = = = = = = = = = = = = ================================================================ she was transfered to the surgery service and went to the or on for: 1. exploratory laparotomy. 2. extensive lysis of adhesions. 3. repair of small bowel serosal injury. 4. right and left component ventral herniorrhaphy. she remained in the icu for 6 days. cri: she had post-op low urine output with atn. she continued on ivf and occasional lasix and diuril. once her urine output picked up, the diuretics were held. she had autodiuresis and her cr began to fall as she mobilized fluids. she continued on d5 1/2ns for several day and we then encouraged po intake. her foleuy was removed as her urine output picked up. abd/gi: she was npo with a ngt. her incision was intact with a moderate amount of serosanguinous drainage. she had a surrounding area of ecchymosis around the incision. she had abdominal jp drains in place with high output (>1000cc drainage). she was started on a po diet on pod 5. her po intake was marginal and we encouraged additional po's. the drain output was still high from drain #2 at time of discharge (1000-2000cc/day). the drains will remain in place until follow-up. cv: she was in normal sinus rhythm with frequent pvc's. she was started on an amiodarone drip. she had occasional bradycardia. she had a episode of rapid afib while repostioning the patient on pod 4 with a rate in the 150's. she converted shortly thereafter with a rate in the 60's. she continued on po amiodarone once back on a diet. resp: she remained intubated and on the vent. she was extubated on and tolerated this. id: she was on cipro/flagyl and ampicillin antibiotics for peritonitis and ischemic bowel. stop antibiotics on . medications on admission: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. labetalol 100 mg tablet sig: one (1) tablet po bid (2 times a day). 3. isosorbide mononitrate 60 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 4. enalapril maleate 10 mg tablet sig: one (1) tablet po bid (2 times a day). 5. nifedipine 30 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). 6. doxazosin 1 mg tablet sig: two (2) tablet po hs (at bedtime). 7. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 8. tramadol 50 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 9. quinine sulfate 325 mg capsule sig: one (1) capsule po hs (at bedtime). 10. metformin 500 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. insulin regular human 100 unit/ml solution sig: one (1) sliding scale injection asdir (as directed). 3. amiodarone 200 mg tablet sig: one (1) tablet po tid (3 times a day) for 1 days. 4. amiodarone 200 mg tablet sig: one (1) tablet po twice a day for 1 weeks: start . then transition to maintenance. 5. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 6. labetalol 100 mg tablet sig: one (1) tablet po bid (2 times a day): please hold for sbp<100 and hr<60. 7. nifedipine 30 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily): hold for sbp < 100 and hr < 60. 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 9. metronidazole 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 3 days: stop on . 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 3 days: stop on . 11. ampicillin 250 mg capsule sig: two (2) capsule po q24h (every 24 hours) for 3 days: stop on . discharge disposition: extended care facility: of discharge diagnosis: hyperkalemia ischemic colitis chronic renal insufficiency malnutrition bradycardia discharge condition: fair weak, deconditioned needs assistance with eating and drinking incision c,d,i with eccymosis 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. followup instructions: please follow-up with dr. in weeks. call ( to schedule an appointment. md, Procedure: Parenteral infusion of concentrated nutritional substances Enteral infusion of concentrated nutritional substances Exploratory laparotomy Other lysis of peritoneal adhesions Transfusion of packed cells Repair of other hernia of anterior abdominal wall Suture of laceration of small intestine, except duodenum Diagnoses: Hyperpotassemia Anemia, unspecified Pure hypercholesterolemia Acute kidney failure with lesion of tubular necrosis Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Unspecified protein-calorie malnutrition Unspecified acquired hypothyroidism Cardiac complications, not elsewhere classified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Accidental puncture or laceration during a procedure, not elsewhere classified Chronic kidney disease, unspecified Other specified cardiac dysrhythmias Peritoneal adhesions (postoperative) (postinfection) Personal history of malignant neoplasm of large intestine Urinary complications, not elsewhere classified Acute vascular insufficiency of intestine Personal history of malignant neoplasm of kidney Acquired absence of kidney Unspecified peritonitis Ventral, unspecified, hernia without mention of obstruction or gangrene