allergies: percocet / tylenol attending: chief complaint: bloody emesis major surgical or invasive procedure: debridement of right 3rd toe and excision of the distal phalanx. picc line placed. history of present illness: history of present illness (source - patient who is tangential, though oriented): 86 y.o. male with pmhx of atrial fibrillation on coumadin, copd, dm, colon ca s/p left colectomy and iron deficiency anemia who presents to the ed with a chief complaint of vomiting blood. patient reports a history of 4 days of antibiotics (augmentin) for a foot infection. he had been experiencing foot pain for appoximately 2 weeks prior to the initiation of antibioitics and for this, he was taking advil every day. he reports experiencing some dark stools throughout this time and on the day of presentation, experienced an episode of hematemesis for which he presented to the ed. he denies abdominal pain, fevers/chills, chest pain, shortness of breath, palpitations. he does also note some drops of blood in the toilet, but no frank hematochezia. . in the ed, initial vitals were: t - 97.7, bp - 131/45, hr - 77, rr - 16, o2 - 97% ra. hct was low at 15, down from baseline of low 20s and inr was elevated to 8.3. ng lavage showed coffee grounds which did not clear with 500ccs and rectal exam revealed black stool that was frankly guaiac positive. gi was consulted and planned for egd once admitted. patient was ordered for 10 mg of vitamin k as well as 2 units of ffp and prbcs. patient's labs were also notable for acute on chronic renal failure with bun/creatinine of 124/3.6 (creatinine up from baseline of 1.5 - 2.0). in the setting of this acute renal failure, troponin was elevated to 0.13 without ischemic changes on ekg. patient was thus admitted to the micu for further management of his severe anemia with renal failure and a troponin leak. . upon arrival to the icu, patient was interactive and in no acute distress with stable vitals. past medical history: dm2 paroxysmal atrial fibrillation on anticoagulation cri- baseline cr 1.5 - 2.0 htn gout copd oa h/o gib (; found to have gastritis, ulcerations, no active bleeding, and angioectasia in colon) h/o hip fx s/p orif/im nail r hip, l hip unclear etiology, previously treated with regular transfusions, now on procrit, baseline 30 h/o pericardial effusion in setting of af with rvr, chf, pleural effusions () s/p turp for prostate enlargement and urinary retention h/o sigmoid colon ca s/p sigmoid colectomy right cheek scc s/p skin graft diastolic chf social history: patient denies tobacco or illicit drugs. he reports occasional alcohol consumption. family history: nc physical exam: on admission vitals: t: 99.2, bp: 119/38, p: 76, r: 22, o2: 96% ra general: awake,alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly rectal: deferred as bed with frank melena ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: labs on admission: 10:45am blood wbc-7.4 rbc-1.82*# hgb-4.8*# hct-15.6*# mcv-86 mch-26.5* mchc-30.9* rdw-19.6* plt ct-245 10:45am blood glucose-175* urean-124* creat-3.6*# na-142 k-4.5 cl-106 hco3-25 angap-16 10:45am blood pt-67.8* ptt-37.0* inr(pt)-8.3* . hct trend 15.6 -> 16 -> 20 -> 22 -> 23.6 -> 25 -> 28.3 . inr trend 8.3 -> 2.2 -> 1.6 -> 1.3 -> 1.2 -> 1.8 . 05:19am blood glucose-115* urean-23* creat-1.3* na-140 k-4.7 cl-108 hco3-24 angap-13 07:20pm blood vanco-15.1 . urine cx : negative . 4:50 pm swab source: right foot. **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci in pairs. smear reviewed; results confirmed. wound culture (final ): staph aureus coag +. moderate growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations rifampin should not be used alone for therapy. corynebacterium species (diphtheroids). moderate growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. . 12:56 pm tissue rt 3rd toe. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 1+ (<1 per 1000x field): gram positive cocci. in pairs and clusters. tissue (final ): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. staph aureus coag +. sparse growth. sensitivities performed on culture # 273-9328s . anaerobic culture (final ): no anaerobes isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (final ): no mycobacteria isolated. fungal culture (final ): no fungus isolated. . cxr : single portable upright chest radiograph: there are low lung volumes. mediastinal and hilar contours are unchanged. there is left basilar atelectasis. there is no right effusion or pneumothorax. pulmonary vasculature is normal. osseous structures are grossly normal. impression: left basilar likely atelectasis. . x-rays of right toes : findings: there is abnormal soft tissue swelling and ulceration in the distal aspect of the right third toe. there appears to be exposed bone, as well as gas at the distal tip of the third toe, highly suspicious for osteomyelitis. the cortical definition of the third distal to until is also irregular consistent with cortical destruction. there is extensive osteopenia. vascular calcifications are present. there is cortical thickening along several of the metatarsal shafts, likely chronic. . right third toe debridement : acute osteomyelitis. . fundoscopic mucosa biopsy : gastric fundic mucosa, biopsy: focal foveolar hyperplasia. . duplex dop abd/pelvis limited & abd ultrasound complete : findings: there is somewhat limited evaluation of the liver due to body habitus and inability to suspend respiration. no intrahepatic biliary ductal dilatation is seen. on dedicated doppler interrogation, there is normal flow and waveforms within the portal and hepatic veins, as questioned. the proximal common duct measures 3 mm in diameter. there is significantly limited visualization of the pancreas. there is limited visualization of theaorta. the gallbladder is normal. the right kidney is normal in size, measuring 9.6 cm, containing a simple, 3.7-cm cyst at the lower pole. the spleen is normal, measuring 11.7 cm. the left kidney is normal in size, measuring 11.0 cm, containing cysts, one of which had a punctate wall calcification. on doppler interrogation, no images of the hepatic artery were obtained due to technical factors. impression: normal portal vein flow, as questioned. somewhat limited evaluation of the liver with no intra- or extra-hepatic biliary ductal dilatation. bilateral renal cysts. . cxr : one ap portable view. comparison with the prior study. lung volumes are somewhat low. streaky density at the lung bases consistent with subsegmental atelectasis and possibly retrocardiac consolidation persists. there is blunting of the left costophrenic sulcus consistent with a small effusion, not apparent previously. a picc line has been inserted on the left and terminates in the region of the mid superior vena cava. impression: evidence for small left pleural effusion. picc line in place. no other significant change. brief hospital course: assessment and plan: mr. is a 86 year old male with history of gibs, colon ca s/p colectomy, atrial fibrillation on coumadin and dm who presents with hct of 15, hematemesis and melena in the setting of a supratherapeutic inr found to have avm s/p clipping. pt also s/p right distal toe amuptation. . # gib: the patient presented to the ed with bloody emesis. ng lavage showed coffee grounds which did not clear with 500ccs and rectal exam revealed black stool that was frankly guaiac positive on arrival. in the ed gi was consulted and the pt received 10 mg of vitamin k as well as 2 units of ffp for inr of 8.3 (in the setting of being on amoxicillin/clavulanate for his toe) and his hct was 15. he received 6 units of blood in the icu and his hct increased to 28 which was above his baseline of 25. he was plaved on an iv ppi and his asa, ccb, and ace were held. during his admission he required 2 egds. the first showed an area of eythema with an overlying clot in the fundus with question of avm below. the clot was unable to be suctioned off. a single red non bleeding angioexctasia was seen in the fundus and was thought to be the source of his bleeding given that his inr was supratherapeutic on admission. three endoclips were placed. the egd was also notable for varices at the gastroesophageal junction, an esophageal ring, and a small hiatal hernia. his second egd was notable for a 1 cm x 2 cm area of localized nodularity of the mucosa of the fundus which was biopsied and showed focal foveolar hyperplasia and no evidence of malignancy. the previously placed clips were present in the gastric junction and a dilated vein was noted at the ge junction. he was discharged on a po ppi. his calcium dose was increased and changed to calcitrol since it is better absorbed when taking protonix. . # likely osteomyelitis of right middle toe: during his admission he required debridement of right 3rd toe and excision of the distal phalanx. tissue cx grew mrsa and corynebacterium. the patient was started on vancomycin, flagyl, and cipro. a picc line was placed and the patient was discharged with vna on long term vancomycin with last dose planned for . he was discharged with lab checks (cbc ast, alt, a ph, tbili chem 7) q friday as well as a vanco trough check on . his wound was dressed with betadine dressing. a special brace was obtained as patient needed to be able to ambulate and even do some stairs at home. rehab was offered but patient declined for social reasons. he was discharged on calcium and vitamin d. . # a fib with rvr: the patient had an episode of a fib with rvr on and received diltiazem 10 iv x2, lopressor 10 ivx1, and an additional dose of diltiazem 60mg po. of note his diltiazem had been held earlier in the day. his diltiazem dose was increased to 240mg daily which was his previous home dose. his coumadin was restarted prior to discharge as his score was 3. at the time of discharge his inr was subtherapeutic at 1.8. he was discharged with plan for inr check on and to have this result faxed to his pcp. . #. iron deficiency anemia: his hct was above his baseline of 25 at the time of discharge. he is being continued on his home iron supplementation. he is on epogen at home. . # acute renal failure: on admission his creatinine was initially elevated to 3.6 from baseline of 1.5 - 2.0. the arf was likely secondary to inadequate renal perfusion secondary to blood loss. his creatinine was 1.3 at discharge. . #. htn: he was discharged on his home lisinopril and ccb. . # copd: patient had intermittent wheezes in the beginning of his hospitalization. he was treated with prn nebs. albuterol prn for sob or wheeze was added to his home regimen of medications including ipratropium inh, fluticasone inh, and montelukast. . # gout: his allopurinol was renally dosed during his arf. he was discharged on his home allopurinol. his colchicine was discontinued as he was doing well off this medication. . #. psych: his home dose of buproprion was continued. . #. dm: he was discharged on his rosiglitazone and was maintained on a diabetic diet while in the hospital. . #. diastolic chf: he lasix was originally held in the setting of decreased uop due to gi bleed and in the setting of arf. he was discharged on his home lasix. . # ppx: pneumoboots, sc heparin, ppi po . # code: full . # emergency contact: and (friends- pt has no family) medications on admission: ipratropium-albuterol lisinopril 10 mg po qd montelukast 10 mg po qd pantoprazole 40 mg po qd rosiglitazone 4 mg po qd coumadin 4 mg po qd iron 325 mg po qd mvi discharge medications: 1. bupropion hcl 75 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 2. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). disp:*1 inhaler* refills:*0* 3. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 5. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. disp:*60 tablet(s)* refills:*0* 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*0* 7. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours) for 5 weeks: last dose . disp:*qs * refills:*2* 9. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: two (2) puff inhalation twice a day. disp:*1 inh* refills:*2* 10. rosiglitazone 4 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 11. vitamin d 1,000 unit tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 12. calcium citrate 250 mg tablet sig: two (2) tablet po twice a day. disp:*120 tablet(s)* refills:*0* 13. multivitamin tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 14. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: inhalation every four (4) hours as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*0* 15. outpatient lab work please have the folllowing labs drawn every friday and have them faxed to your pcp . at cbc ast, alt, a ph, tbili chem 7 16. furosemide 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 17. allopurinol 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 18. outpatient lab work inr check on friday and fax to dr. at 19. outpatient lab work check vancomycin trough on and fax to dr. . 20. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po once a day. disp:*30 capsule, sustained release(s)* refills:*0* 21. epogen 10,000 unit/ml solution sig: one (1) ml sc injection once a week: on fridays. disp:*qs * refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: primary: 1) upper gi bleed 2) toe osteomyelitis . secodary: 1) dm2 2) paroxysmal atrial fibrillation on anticoagulation 3) cri- baseline cr 1.5 - 2.0 4)htn 5) gout 6) copd 7) oa 8) h/o gib (; found to have gastritis, ulcerations, no active bleeding, and angioectasia in colon) 9) h/o hip fx s/p orif/im nail r hip, l hip 10) unclear etiology, previously treated with regular transfusions, now on procrit, baseline 30 11) h/o pericardial effusion in setting of af with rvr, chf, pleural effusions () 12) s/p turp for prostate enlargement and urinary retention 13) h/o sigmoid colon ca s/p sigmoid colectomy 14) right cheek scc s/p skin graft 15) diastolic chf discharge condition: stable on vancomycin iv for osteomyelitis. inr subtherapeutic at 1.8. discharge instructions: you were admitted to the hospital for an upper gastrointestinal bleed. a source of bleeding was found in your stomach and it was clipped. you received blood transfusions and now your blood count is stable. while in the hospital you were also found to have osteomyelitis in your toe which is an infection of the bone. you were started on a long-term iv antibiotic called vancomycin. you stayed in the hospital for one day longer than expected because your heart was in atrial fibrillation and beating quickly. we restarted your diltiazem at it's previous dose. . the following changes were made to your medications: -vancomycin was started for your osteomyelitis -albuterol was added to be taken as needed for shortness of breath or wheeze -colchicine was discontinued since you are doing well off of it -your calcium dose was increased and changed to calcitrol since it is better absorbed when you are taking protonix . no other changes were made to your medications. you should take all medications as detailed on the attached sheets. . you should return to the emergency room if you develop any of the following: - vomiting of blood or coffee grounds like substance - black tarry stools - lightheadedness or palpitations - chest pain - shortness of breath - persistent fever > 100.4 - worsening pain or redness/blackness around the toe followup instructions: please call dr. office and make an appointment for 2 weeks from now for podiatry . please call dr. office and make a follow up appointment for sometime in the next 1-2 weeks , . . provider: , md phone: date/time: 8:00 provider: , md phone: date/time: 11:00 provider: , m.d. phone: date/time: 10:00 Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Excisional debridement of wound, infection, or burn Endoscopic control of gastric or duodenal bleeding Other partial ostectomy, other bones Diagnoses: Congestive heart failure, unspecified Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Acute kidney failure, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Gout, unspecified Atrial fibrillation Chronic kidney disease, unspecified Long-term (current) use of anticoagulants Personal history of malignant neoplasm of large intestine Chronic obstructive asthma, unspecified Chronic diastolic heart failure Angiodysplasia of stomach and duodenum with hemorrhage Acute osteomyelitis, ankle and foot Osteoarthrosis, unspecified whether generalized or localized, other specified sites