allergies: patient recorded as having no known allergies to drugs attending: chief complaint: muscle twitching and weakness to osh major surgical or invasive procedure: paracentesis paracentesis tips procedure paracentesis history of present illness: this is a 60 year old woman with alcohol-induced cirrhosis, now sober > 6 months, currently undergoing evaluation for liver transplant, transferred from for further management. the patient was most recently admitted to between and for a colonoscopy and egd with polypectomy and biopsy. the pt has known ascites and is on a stable regimen of lasix and aldactone but still requires weekly paracentesis to control her ascites (normally >5l removed at a time by dr. ). she presented to endoscopy suite for her usual paracentesis and reported feeling weak with muscle twitches on . blood pressure at the time was found to be 70/50 leading to an ed evaluation where the blood pressure was confirmed and in addition she was found to have a k of 7.5 and na of 117. in addition, she had a bun/cr of 79/2.6, t.bili of 1, alb of 2.4, inr of 1.07 and ammonia of 9. she was given bicarb, insulin/d50 and oral kayexalate. ecg demonstrated no peaked t waves (however this was done after treatment). k decreased to 6.7. she was subsequently admitted to the icu for further management. the pt was hydrated overnight with increase in systolic bp to 80s. in addition, she was given albumin and ceftriaxone iv. on , paracentesis was performed with removal of 2l of fluid. the ascites fluid (after antibiotics) demonstrated rbc of 19,000 and wbc of 165 with 48% polys. bun/cr improved to 62/1.6 but urine output remained poor. the pt was also given a dose of lactulose as she had not had a bm since tues. patient was subsequently transferred to the floor. past medical history: 1. alcoholic cirrhosis -regular therapeutic paracentesis -no hx gi bleed, no h/o varices -no hx encephalopathy 2. tubulovillous adenoma of the colon 3. osteopenia with hx of t11 compression fracture social history: etoh: quit , states that eve, she celebrated 6 months of being sober. tobacco: smoked since she was 13 years old, 1ppd now, at the most, she was smoking 2-3ppd. no h/o ivda. family history: mother with h/o mi, cva. father with h/o colon cancer. physical exam: vitals: temp 96.4 bp: 74/57 p: 100 rr: 16 o2sat: 97% ra general: chronically ill-appearing cachectic female in nad. lying flat and breathing comfortably on room air. heent: perrl, eomi. no scleral icterus. mm slightly dry, oropharynx clear. neck: jvd elevated ~10cm. no lad. supple, good rom. lungs: bibasilar crackles cv: tachycardic with rrr s1 and s2 audible, soft systolic murmur heard at apex abd: prominent ascites, umbilicus protruding, with prominent veins over abdomen. tympanitic to percussion. decreased bowel sounds. no masses. unable to feel liver or spleen ascites. peripheral vasc: brownish discoloration to lower legs bilaterally with dry skin, stasis changes. neuro: motor , sensory , no asterixis, cn 2-12 intact. appropriate in speech and conversation. aox3. pertinent results: studies at hosp: cxr portable at osh: "unremarkable with clear lungs" na: 123 (inc. from 117 at time of admission) k: 3.9 (. from 7.5 at time of admission) cl: 93 co2: 22 bun: 62 cr: 1.6 glucose: 120 ca: 7.8 . wbc: 14 hct: 39.9 plt: 149 . inr: 1.14 pt: 12 . tot prot: 4 albumin: 2.2 tot. bili: 1 alk phos: 77 alt: 37 ast: 29 . colonoscopy : polyp in the proximal ascending colon s/p polypectomy. . egd : polyp in the duodenum s/p polypectomy (reactive/inflammatory cellular change vs. adenomatous tissue insufficient amunt of tissue for dx), nml esophagus, nml stomach, no varices. . abdominal ct : 1. cirrhotic liver. no mass lesion demonstrated on the current ct. 2. large amount of intra-abdominal and pelvic ascites with mildly nlarged spleen and portosystemic collaterals including small enhancing esophageal varices in keeping with background portal hypertension. 3. cholelithiasis. 4. a 1.3-cm right adrenal nodule versus adjacent venous varix. 5. variant hepatic arterial anatomy as described. . p-mibi : no anginal type symptoms or ischemic ekg changes with stress and normal myocardial perfusion with normal left ventricular cavity size and function (ef 78%). . tte : -la: normal in size. -lv: wall thickness, cavity size, and systolic function are normal (lvef>55%). -rv: chamber size and free wall motion are normal. -aortic valve: no ai, as -mitral valve: trivial mitral regurgitation. -pa pressure: estimated pa systolic pressure is normal. . hepatic hunt tips : angiographically successful placement of a tips from the right portal vein to the middle hepatic vein. portosystemic gradient before tips was 24 mmhg. portosystemic gradient after tips was 9 mmhg . abd/pel ua : patent tips with wall to wall flow. flow velocities in the patient's tips range from 56 cm proximally to 199 in the mid tips, and 162 in the distal tips. expected reversal of flow in the left portal vein and anterior right portal vein is present. unchanged large quantity of ascites in this patient with evidence of cirrhosis. . cxr: slightly increased right lower lobe opacity with volume loss, most likely representing atelectasis. if there is a strong clinical suspicion for pneumonia, further evaluation by pa and lateral views may be helpful brief hospital course: this is a 60 year old woman with alcoholic cirrhosis, presented as transfer from after found to be weak with muscle twitching on . k at that time was 7.5 with na 117, treated with bicarb, insulin/d50 and oral kayexalate with resultant k 3.9. her na improved to 123. also noted at osh to be in arf with cr 2.6, improved to 1.6 after ivf hydration, felt most likely to be prerenal given recent increase in both spironolactone and lasix, and not hepatorenal given improvement with diuretics being held and ivf hydration. platelets noted to be 149, inr 1.17. the pt usually undergoes large volume paracentesis with weekly draining of 5-6l. she has not had abdominal tenderness, fever, wbc at osh 14, however, she underwent paracentesis at with 2l removed, showing 165 wbc after ceftriaxone given. she also received albumin at osh. of note, she has been undergoing liver transplant eval with dr. . . while at she was changed from ceftriaxone to cipro for sbp pprx. she had a paracentesis on (3 liters), (2 liters), and (2 liters) all of which were negative for sbp. unfortunately her renal function continued to worsen (1.0 -> 2.2). sodium also stayed in the 120's despite fluid restriction. furthermore she remained hypotensive 60's to 70's. difficult to assess patient's volume status so renal and liver felt patient could be better managed with closer hemodynamic monitoring. in the micu, cvl was placed. per renal, it was felt pt had hrs and atn. initially her uo was low, so after albumin was ineffective in treating her bp, she was started on levophed. she underwent paracentesis x2 with 2 l taken off on and 6 l taken off on . on the pt was started on ceftriaxone for tx of ?sbp on gram stain from paracentesis (elevated wbc in setting of being on abx). she received frequent prbc and albumin while in the unit. the pt was found to have c diff and was started on flagyl on . she was also found to have yeast in her urine so her foley was changed. the pts levophed gtt was weaned off on and the pt was transferred to the floor. the pt underwent 5 l volume paracentesis on the floor on . early am of her sbp was noted to be in the high 60's with a urine output of 27cc over 8 hrs. her creat increased from 1.0 to 1.5. she was transferred back to the micu for a levophed gtt until . she received multiple units of ffp, albumin, therapeutic paracentesis on and . tips procedure was performed on . patient remained stable after the procedure. a therapeutic tap was performed on prior to discharge to rehab where she will be followed by the liver team at . . #?spontaneous bacterial peritonitis: of note, pt's paracentesis at was significant for 165 wbc with 48% polys (by criteria, neg for sbp, although pt did receive ceftriaxone prior to paracentesis). iv ceftriaxone was continued for possible sbp. the pt has remained afebrile, with wbc ct 14 on osh labs. on arrival at , pt was afebrile, nl wbc ct with minimal abdominal tenderness, though abdomen was very distended 3 days ago, tense, with umbilical hernia protruded and necrotic area present on hernia. she is s/p paracentesis , with umbilical hernia less swollen, blue. abdomen appeared less tense but still distended, pt overall appeared to be improving clinically. no nausea or vomiting. paracentesis : wbc 222 with 30 polys, 45 lymphs, 14 monos. rbc. epeat paracentesis was aborted (given her pressures were 60s/30s) her baseline bp is 70s/40s. she is consented for a 2nd para. for her low bp, she was given 50g albumin, positioned on left side (compression of ivc given massive ascites?), with improvement in bp. d/c'd iv ceftriaxone and started po ciprofloxacin. pt received 50g albumin 25% during 1st paracentesis, then was receiving qd albumin 25% 25g. elevated wbc on ascites fluid in setting of being on abx (300 wbc with 77%poly on , 344 wbc with 54% poly ) prompted reinitiation of ceftriaxone on . pt was continued on ceftriaxone (start ) until . she underwent paracentesis x2 with 2 l taken off on and 6 l taken off on . she again underwent paracentesis on , , and . given that the pts ascites fluid did not grow out any organisms on culture, it was felt the ceftriaxone no longer needed to be continued. she was then switched to levofloxacin for sbp ppx then eventually switched to ciprofloxacin 750mg qwk. . #hypotension: felt to be due to pts cirrhosis and hrs. pt was transferred to the micu on for low uo and hypotension. she was continued on a levophed gtt until . she was also started on octreotide and midodrine. in the micu, cvl was placed. per renal, it was felt pt had hrs and atn. initially her uo was low, so after albumin was ineffective in treating her bp, she was started on levophed. on transfer back to the floor, the patient was still hypotensive down to sbp of 70, but asymptomatic. her sbp is normally in 70's since ascites started to be a problem. she was also likely intravascularly dry. for low bp, the pt received albumin 60 g on gram . early am her sbp was noted to be in the high 60's with a urine output of 27cc over 8 hrs. her creat increased from 1.0 to 1.5. she was transferred back to the micu for a levophed gtt. the levophed drip was weaned off on . she received multiple ns boluses, albumin boluses, and ffp. on transfer back to the floor the pts sbp ranged 80s-100s. on the pts sbp fell again to 77, requiring 25 gm albumin. the pt was started on albumin 25 gm on , resulting in stabilization of her pressures. her octreotide was discontinued on , but her midodrine was continued. daily albumin was discontinued on . midodrine was discontinued on . patient was resumed on low dose lasix and aldactone on which were held on . patient's bp remained in the high 80's to 90's up until discharge to rehab. . #low grade fever: patient had low grade fevers from concerning for infection v atelectasis. no longer febrile. repeat ua negative was negative. blood cx from line and peripherally no growth to date. her central line was dicontinued and now has piv. repeat cxr prelim showed new atelectasis, incentive spirometer to bedside. rechecked for c diff given recent history which was negative. attempt at discontinuing foley was unsuccessful. patient's oxycodone was discontinued and she would benefit from another voiding trial at rehab. . #alcoholic cirrhosis: pt of dr. who had previously been undergoing evaluation for liver transplantation. pt appears to have worsening ascites, h/o weekly large volume paracenteses 5-6l. no history of gi bleeding or varices (recent egd demonstrated no esophageal varices). pt was not encephalopathic, no asterixis. child class calculated at 7, or class b (based on most recent labs, however, pt receiving albumin). meld score of 14. s/p paracentesis , drained off ~3l fluid. pt's umbilical hernia decreased,no longer blue, still with necrotic erosion at tip. repeat paracentesis aborted. pt given 2l paracentesis and 6l on . tapped 5 l on which had 156 wbc with 48 polys, saag greater than 1.1. tapped 4l on and 6 l on . the pt was again tapped 4l on . para with 4 l removed (with 4 units ffp, 50 gm albumin) revealed: alb 2.3, wbc 250, 27%poly, rbc )--negative for sbp, gram stain negative. pt was maintained on 1 l fluid restriction throughout her stay. she was also maintained on lactulose. the pt was taken for tips procedure on given her diurectic refractory ascites. she was given 2 u ffp and 3gm unasyn prior to the procedure. ruq following the procedure revealed flow velocities in the patient's tips range from 56 cm proximally to 199 in the mid tips, and 162 in the distal tips. daily albumin was discontinued on . a therapeutic tap was performed on prior to discharge. . #acute renal failure, initially resolved, thought prerenal etiology: pt with cr found to be 2.6 on , highest was 3.1, improved to 1 after ivf hydration. held spironolactone and lasix at osh. thought most likely to have prerenal etiology given improvement after ivf hydration with diuretics held. the pt was also felt to have a componenet of hrs. continue to hold diuretics during this admission. pt was restarted on octreotide and midodrine. she was kept on a low sodium diet with fluid restriction to 1200cc/day as per nutrition recs/pt request. she was initially placed on bicitra but this was changed to baking soda.pts cr worsened again on from 1 on up to 1.8. again, this was felt to be prerenal/hrs. urine chemistries revealed a fena of 0.15%. the pts cr gradually resolved to 1.1 on . her cr began to slowly increase up to 1.2 on , but this resolved with starting daily albumin on . patient's cr was 0.5 on day of discharge. . #hyponatremia: treated with fluid restriction, diuretics held. pt received frequent albumin as well. resolved to the low 130s initially and then up to the upper 130s. her na was noted to decrease any time that she did not receive enough albumin. on , the pts na dropped back to 131, however it rose again to the upper 130s with initiation of daily albumin on . resolved. . #c diff colitis: pt + for c-diff colitis toxin on : flagyl started po and continued flagyl (start ) for 14 day course. multiple (>4) repeat culture for c diff were negative. . #lll pna: the pt was diagnosed with ?lll pna on cxr on . initially she was going to be continued one a 10 day course of ceftriaxone(given that she was being treated for sbp as well), however the ceftriaxone was changed to levofloxacin given the pts ascites fluid did not grow any organisms. patient completed a 10 day course of antibiotics with improvement of her respiratory status. . #anemia - iron 20, tibc 90, ferritin 232, transferrin 69. likely both anemia of chronic disease and iron deficieny. pt was started on iron supplementation. patient received 1u prbcs on . hct 31.6 on discharge. . #osteopenia: continued calcium supplementation/multivitamin. . #*funguria: +yeast in ua. foley was changed. the pt received an amphotericin bladder wash . she also was started on fluconazole 100mg iv q24 hr on for a 5 day course (finish ). . #uti: the pt was found to have an enterococcal uti from urine cx on . the pts foley was changed and repeat ua was negative. given the pt had no fever or elevated wbc, she was not started on abx. attempt at discontinuing foley was unsuccessful. patient's oxycodone was discontinued and she would benefit from another voiding trial at rehab. . #coagulopathy: likely related to liver dx. patient was given vit k prn, ffp prn for procedure. but has not required these otherwise. . # fen: dobhoff placed for tube feeds with banana flakes; also regular diet with boost. pt was started on tube feeds however is taking good amount of po. will need a calorie count to re-evaluate intake. repleted lytes prn. bicarbonate was discontinued on . . #ppx: heparin sub q tid for dvt ppx, colace, senna, lactulose and ppi for gi ppx. . #communication: daughter (hcp) . #full code medications on admission: medications at home: 1. spironolactone 200 mg qam 100 qpm 2. furosemide 80 mg qam 40 mg qpm 3. potassium 7.5 meq twice a day. 4. calcium 600 mg twice a day. 5. multi-vitamin hi-po one tablet once a day. . medications on transfer out of icu: albumin ceftriaxone 1 gm iv q 24 hr start calcium carbonate 500 mg po tid anzemet prn hep sc lactulose 30 tid to bm midodrine 15mg tid mvi na bicarb 650 vit d 50,000 uqwk octreotide 200mcg sc q8h protonix 40mg qday senna 1 tab qday vit d 50,000 units qweek ambien prn oxycodone prn atrovent neb prn flagyl 500 mg tid discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. multivitamin capsule sig: one (1) cap po daily (daily). 4. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 5. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). 6. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week (th). 7. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 8. zinc oxide-cod liver oil 40 % ointment sig: one (1) appl topical prn (as needed). 9. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 10. insulin regular human 100 unit/ml solution sig: one (1) unit injection asdir (as directed). 11. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid with meals (). 12. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed. 13. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day) as needed: titrate to bm /day. 14. dolasetron mesylate 12.5 mg iv q8h:prn 15. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day). 16. ciprofloxacin 250 mg tablet sig: three (3) tablet po 1x/week (we). discharge disposition: extended care facility: & rehab center - discharge diagnosis: 1. spontaneous bacterial peritonitis 2. alcoholic cirrhosis with ascites 3. acute renal failure, hepatorenal syndrome 4. c diff colitis 5. uti 6. hypotension, resolved 7. hyponatremia, resolved discharge condition: stable discharge instructions: if you experience any abdominal pain, fever, chills, nausea or vomiting, please report to the emergency room immediately. . please follow up with your doctors. . please take all of your medications as directed. followup instructions: provider: , md phone: date/time: 1:00 . please follow up with your primary care phyisican dr. within 1 week of discharge. please call to schedule the appointment. Procedure: Venous catheterization, not elsewhere classified Enteral infusion of concentrated nutritional substances Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Percutaneous abdominal drainage Closure of skin and subcutaneous tissue of other sites Transfusion of packed cells Transfusion of other serum Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Infusion of vasopressor agent Diagnoses: Pneumonia, organism unspecified Thrombocytopenia, unspecified Tobacco use disorder Acute kidney failure with lesion of tubular necrosis Urinary tract infection, site not specified Alcoholic cirrhosis of liver Hepatorenal syndrome Acquired coagulation factor deficiency Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Other and unspecified alcohol dependence, in remission Candidiasis of other urogenital sites Hypotension, unspecified Intestinal infection due to Clostridium difficile Iron deficiency anemia, unspecified Disorder of bone and cartilage, unspecified Umbilical hernia without mention of obstruction or gangrene Spontaneous bacterial peritonitis Chronic ulcer of other specified sites Other specified noninflammatory disorders of vulva and perineum