allergies: meropenem attending: chief complaint: workup of fuo and pancreatic cyst major surgical or invasive procedure: ct-guided drainage and placement of a drain in a pancreatic pseudocyst packed rbc transfusion 1 unit packed red blood cell transfusion central venous line insertion history of present illness: patient is a 29-year-old man who had a very complicated medical course at for alcoholic pancreatitis in that required a prolonged icu stay, complicated by ards, , asystolic cardiac arrest, placement of a tracheostomy, and diffuse neurologic injury and cognitive impairment from complications and subsequent development of a seizure disorder. he presented to medical center on with chief complaint of fevers, nausea, vomiting, flank pain, and mild elevation of pancreatic enzymes. during his admission at , fever workup was negative. per report, his bandemia on day of discharge was 28% (with a white count of 14). he underwent ct of the abdomen that showed a multilobulated cystic lesion in the tail of the pancreas measuring 9.6 by 5 cm consistent with a pseudocyst. there was moderate peripancreatic inflammatory stranding. he continued to have fevers during the hospital stay to as high as 103.6. abdominal exam was reportedly benign throughout. inflammatory markers were elevated to crp of 368 and esr of 122. he was evaluated during the hospital admission by infectious diseases service, and they were reluctant to start antibiotics given that there was no clear source of infection and he remained clinically stable. the id consultants had recommended consideration of tapping the pancreatic pseudocyst visualized on ct scan. the patient was also seen by gastroenterology who favored starting empiric broad-spectrum antibiotics, although antibiotics were never started. the patient was then evaluated by neurology for his seizure disorder history (and the fact that he had recently started lamictal in early ); the neurology service had recommended to consider decreasing the dose of lamictal, as it could potentially be the cause of a drug-induced fever. additionally, the patient was seen by rheumatology who wanted to rule out an occult vasculitis - labs were sent for , anca and immunoglobulins, rf and complement. all of these studies are still pending at time of transfer. per the transfer summary notes, blood cultures from are still negative, and a urine culture from admission was likely contaminated. as above, he was never treated with antibiotics. prior to his transfer to , a discussion was held between patient's family and dr. , the intensivist at who took care of him during his admission in . the decision was made to transfer the patient to for further workup of the pancreatic lesion visualized on ct scan. ros: currently, patient denies chest pain, shortness of breath, nausea, headache, dizziness, abdominal/flank/back pain, or urinary complains. he feels okay. past medical history: - insulin dependent diabetes since - depression and anxiety - history of hemorrhagic pancreatitis in - history of asystolic arrest with resultant anoxic brain injury - history of seizure disorder on triple therapy social history: the patient lives with his family. his mother is a physiatrist and his father is a rheumatologist. his brother is a dermatologist. prior to the patient's admission in for severe pancreatitis, he was an engineer with a master's degree. the patient is not married and he is without children. his remote alcohol abuse history was significant for 5-6 years, drinking 6 mixed drinks daily with withdrawl symptoms. he used to smoke 1.5 ppd of cigarrettes. family history: mother with dm2. physical exam: afebrile, vss general: well-appearing indian man in no acute distress. heent: non-icteric sclera, moist mucus membranes. neck: supple, no lad. heart: rrr, normal s1/s2, lungs: clear bilaterally anterior fields. abdomen: soft, non-tender, no rebound or guarding. extremities: warm, well-perfused, without edema; patient is wearing braces over the shins for foot support. pertinent results: osh labs: : -wbc 16.3, 80% polys -hct 35.4 -mcv 78 -plt 398 -cre 1.1 -bun 12 -co2 27 - 89 -alb 4.1 -tbi 0.3 -alt 18 -ast 21 -lip 106 (uln 59) -esr 122 -ua >100 glu, sm blood, >300 pro, neg nit, neg leuks : -wbc 14.6, 28% bands -hct 28.0 -mcv 76 -plt 388 -cre 0.8 -bun 8 -co2 25 admission labs at : 10:59pm glucose-223* urea n-10 creat-0.9 sodium-127* potassium-4.1 chloride-92* total co2-23 anion gap-16 10:59pm alt(sgpt)-15 ast(sgot)-13 ld(ldh)-195 alk phos-132* amylase-82 tot bili-0.3 10:59pm lipase-125* 10:59pm albumin-3.4* calcium-8.5 phosphate-2.8 magnesium-1.7 10:59pm triglycer-156* 10:59pm osmolal-271* 10:59pm wbc-20.1*# rbc-3.95* hgb-9.9* hct-30.1* mcv-76* mch-25.2* mchc-33.0 rdw-13.3 10:59pm neuts-76.9* lymphs-18.3 monos-2.9 eos-1.2 basos-0.8 10:59pm plt count-566* 10:59pm pt-14.2* ptt-25.5 inr(pt)-1.2* . cxr pm preliminary report !! wet read !! r-ij tip at level of superior cavoatrial junction. lucency in right apex however no definite pleural line seen to suggest pneumothorax. otherwise stable radiograph; left effusion, atelectasis. . cxr am findings: the moderate left pleural effusion is unchanged. there is new elevation of the left hemidiaphragm with associated increase in the underlying gastric bubble. no right effusion is seen. the lungs are clear. the cardiac and mediastinal silhouettes are unchanged. there is no pneumothorax identified. . impression: 1. unchanged moderate left pleural effusion. 2. new elevation of the left hemidiaphragm. . . ct abdomen/pelivs final read: ct of the abdomen: the left hemidiaphragm is elevated, likely due to significant left lower lobe collapse. the spleen enhances homogeneously. in the left upper quadrant, there is a multiloculated pancreatic pseudocyst. a pigtail catheter enters from the left posterior approach with pigtail appropriately situated within the pseudocyst cavity. the dominant compartment has decreased moderately in size compared to one day prior, now measuring 7.9 x 2.9 cm, previously 10.2 x 5.2 cm. small foci of air within the superior aspect of the collection have likely been introduced by the pigtail catheter. there is no free air to suggest viscus perforation. the pseudocyst insinuates along the greater curvature of the stomach and extends inferiorly encompassing the body and tail of the pancreas. there are calcifications of the pancreatic head, consistent with the history of pancreatitis. no hyperdensity surrounding the pseudocyst to suggest hemorrhage. the left adrenal gland is again thickened as previously, likely reactive. . the liver, gallbladder, kidneys, and right adrenal gland are normal. the visualized small and large bowel loops are of normal caliber. there is no ascites. multiple small retroperitoneal lymph nodes are unchanged from prior exam and likely reactive. . there are no concerning lytic or sclerotic lesions. mild degenerative changes are seen at t8-9 with small anterior osteophytes. . impression: . 1. new moderate nonhemorrhagic left pleural effusion with significant atelectasis of the left lower lobe and lingula, causing elevation of the left hemidiaphragm. . 2. left pseudocyst pigtail drain in appropriate position, with moderate decrease in size of the pseudocyst. . osh studies: ct abdomen pelvis (): no report sent, but cd sent and uploaded. per discharge summary the report was significant for a multilobulated cystic lesion in the tail of the pancreas measuring 9.6 by 5 cm consistent with a pseudocyst. additionally there was moderate peripancreatic inflammatory stranding present. chest x-ray (): the heart is normal in size. the aortic contaours and mediastinal structures are normal in appearance. the lungs are clear with no active infiltrate, pulmonary vascular congestion, or pleural effusions. there is no acute osseaous pathology identified. impression: normal chest. electrocardiogram (): sinus tachycardia 123, na, ni, no ischemic changes. mri abdomen (): in the region of the distal body and tail of the pancreas, there is a thin-walled, multiloculated t2 hyperintense lesion measuring approximately 7.4 cm x 4.6 cm. within the lesion, there are multiple t2 hypointense foci, most likely represent debris. this lesion communicates with an additional t2 hyperintense lesion with a thick enhancing wall in the midline near the head of the pancrease measuring approximately 3 cm by 1.9 cm. this also has an enhancing internal septation. differential for this lesion includes pseudocyst versus cystic pancreatic neoplasm. admission labs: 10:59pm blood wbc-20.1*# rbc-3.95* hgb-9.9* hct-30.1* mcv-76* mch-25.2* mchc-33.0 rdw-13.3 plt ct-566* 06:15am blood wbc-16.3* rbc-3.82* hgb-9.6* hct-29.4* mcv-77* mch-25.0* mchc-32.5 rdw-13.3 plt ct-488* 08:35am blood wbc-18.4* rbc-3.68* hgb-9.5* hct-27.9* mcv-76* mch-25.7* mchc-33.9 rdw-13.3 plt ct-564* 10:59pm blood pt-14.2* ptt-25.5 inr(pt)-1.2* 10:59pm blood glucose-223* urean-10 creat-0.9 na-127* k-4.1 cl-92* hco3-23 angap-16 06:15am blood glucose-234* urean-9 creat-0.8 na-126* k-4.1 cl-92* hco3-23 angap-15 08:35am blood glucose-156* urean-7 creat-0.8 na-126* k-4.5 cl-91* hco3-21* angap-19 10:59pm blood alt-15 ast-13 ld(ldh)-195 alkphos-132* amylase-82 totbili-0.3 06:15am blood ld(ldh)-196 ck(cpk)-52 06:20am blood alt-13 ast-11 alkphos-130 amylase-47 totbili-0.4 05:48am blood alt-13 ast-11 totbili-0.2 10:59pm blood lipase-125* 06:20am blood lipase-41 10:59pm blood albumin-3.4* calcium-8.5 phos-2.8 mg-1.7 05:35am blood calcium-8.2* phos-3.2 mg-1.7 06:20am blood iron-12* 06:15am blood caltibc-163* hapto-580* ferritn-1547* trf-125* 06:20am blood caltibc-148* ferritn-1368* trf-114* 10:59pm blood triglyc-156* 10:59pm blood osmolal-271* cxr pa/lateral : findings: as compared to the previous radiograph, there is no relevant change. borderline size of the cardiac silhouette without pulmonary edema. small left pleural effusion with left basal atelectasis. no evidence of pneumonia, no pneumothorax. the previously placed right internal jugular vein catheter has been exchanged against a right tip line. the tip of the line projects over the inflow tract of the right atrium. ekg : sinus tachycardia with non-specific st-t wave abnormalities. compared to the previous tracing of no diagnostic interim change. ekg : sinus tachycardia with non-specific st-t wave abnormalities. compared to tracing #1 there is no change. ct abd/pelvis : impression: interval decrease in the size of pancreatic pseudocyst. pigtail drain previously inside the pseudocyst is no longer in the proper location with the coiled tail pulled against the posterior abdominal wall. micro: all blood/urine cultures negative c diff negative abscess: gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and chains. smear reviewed, possible short gram positive rods in chains. fluid culture (final ): this is a corrected report (). reported by phone to dr. @ 0955a, . streptococcus . sparse growth. identification performed by laboratories. previously reported as gram positive rod(s) (). anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): no fungus isolated. discharge labs: 08:28am blood wbc-11.5* rbc-3.64* hgb-9.3* hct-28.8* mcv-79* mch-25.6* mchc-32.4 rdw-14.4 plt ct-594* 06:06am blood glucose-97 urean-17 creat-1.0 na-135 k-4.4 cl-100 hco3-26 angap-13 08:28am blood glucose-139* urean-15 creat-1.0 na-136 k-4.6 cl-101 hco3-27 angap-13 08:28am blood calcium-9.8 phos-3.1 mg-1.7 07:35am blood tsh-4.0 06:21am blood cortsol-16.1 05:40am blood levetiracetam (keppra)-test 06:21am blood aldosterone-test 06:21am blood renin-test 02:29pm other body fluid amylase- 10:12am other body fluid organism referred for identification, aerobic bacteria-test name brief hospital course: 29-year-old man with a history of severe etoh pancreatitis complicated by anoxic brain injury and seizure disorder who was transferred from osh for evaluation of ongoing fevers, and found to have pancreatic pseudocyst with abcess. . # pancreatic pseudocyst with abcess: the patient presented to the with several weeks of subjective fevers, nausea, and vomiting and was found to have an enlarging pancreatic pseudocyst on ct abdomen/pelvis and was transfered to . on hd 3, patient had a percutaneous drain placed by ir with aspiration from the pseudocyst showing gram positive rods. the specimen was sent to the for speciation. while awaiting final speciation, he was treated with iv vancomycin and ampicillin-sulbactam. pancreatic drain fluid showed amylase >40,000 suggesting a communication between the pancreatic duct and the abcess cavity. pancreatic surgeons were consulted who recommended ercp to evaluate pancreatic duct morphology. ercp was not performed in house as there were concerns regarding the inflammation of the pancreas and risk of post-ercp pancreatitis. a repeat ct scan showed marked decrease in size of the psuedocyst with drain having been pulled out to the peritoneum. the drain was removed the following day by surgery. abscess specimen grew back strep , id the patient was to continue iv ceftriaxone for at least 5 weeks, full treatment to be guided by infectious disease. . # hyponatremia: the patient's sodium was 127 at time of transfer and trended down to 124. he trended down to a low of 119 and suffered two tonic-clonic seizures as described below. the hyponatremia was thought to be secondary to siadh. was initially corrected with hypertonic saline, then started on fluid restriction and tabs and sodium normalized. there was concern that sertraline was causing the hyponatremia, dosing was decreased. . # seizure disorder: the patient had 2 seizures in the setting of hyponatremia. this was corrected in the intensive care unit with hypertonic saline. neurology was consulted and did not recommend making any changes to the seizure regimen. once back on the general medicine floor, the patient had an episode of shaking leg movements, tachycardia to 170s that was concerning for seizure disorder, however neurology examined patient and did not think this was seizure disorder. . # tachycardia - the patient remained tachycardic during his hospitalization. ekgs revealed this to be a sinus tachycardia. cardiology was consulted and thought this was either related to inappropriate sinus tachycardia or anemia. the patient was not responsive to fluid boluses or blood transfusion. there was thought that the patient's pleural effusion may have been the cause of the tachycardia, however after speaking to interventional pulmonology and interventional radiology, they felt that the effusion was not large enough to cause this or tap. the patient was started on a low dose of metoprolol to control the heart rate. the effusion should be followed with x-rays to make sure it is not enlarging or becoming loculated which may be indicative of infection. . # nausea - the patient had chronic nausea during his hospitalization with some episodes of emesis. he was treated with anti-emetics, including standing compazine with zofran prn which did help. he was also started on a low fat diet and omemprazole to try and minimize his nausea. . # diabetes mellitus: was consulted to help control the patients diabetes. his regimen was changed to 42 units of lanuts in the morning, and recommended a new sliding scale that was provided. his blood sugar was well controlled on the new regimen. . # anemia: the patient's anemia was thought to be secondary to iron deficiency and anemia of chronic disease. he did receive a blood transfusion with appropriate rise in hematocrit. . # chronic cough - thought to be secondary to diaphragmatic irritation from psuedocyst. treated with anti-tussives. # emergency contact: brother . . # code status: full code. medications on admission: (per osh records) - acetaminophen 325-650 mg q6h prn - insulin aspart per sliding scale four times daily with meals - insulin glargine 29 units in the morning - carbamazepine 800 mg q12h - lamotrigine 50 mg q12h - levetiracetam mg q12h - sertraline 100 mg q12h - zofran 4 mg iv q8h prn (usually before seizure meds) discharge medications: 1. acetaminophen 325 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for pain. 2. carbamazepine 400 mg tablet sustained release 12 hr : two (2) tablet sustained release 12 hr po every twelve (12) hours. 3. lamotrigine 50 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po every twelve (12) hours. 4. levetiracetam 1,000 mg tablet : two (2) tablet po every twelve (12) hours. 5. prochlorperazine maleate 10 mg tablet : one (1) tablet po every six (6) hours as needed for nausea. :*60 tablet(s)* refills:*0* 6. insulin glargine 100 unit/ml solution : forty two (42) units subcutaneous qam. :*qs * refills:*2* 7. ceftriaxone 2 gram recon soln : two (2) grams intravenous every twenty-four(24) hours for 5 weeks: dosing will be adjusted per infectious disease doctors. :*qs * refills:*0* 8. metoprolol succinate 25 mg tablet sustained release 24 hr : one (1) tablet sustained release 24 hr po once a day. :*30 tablet sustained release 24 hr(s)* refills:*0* 9. zofran odt 4 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po every four (4) hours as needed for nausea. :*40 tablet, rapid dissolve(s)* refills:*0* 10. sertraline 25 mg tablet : three (3) tablet po once a day. :*90 tablet(s)* refills:*0* 11. humalog 100 unit/ml cartridge : per sliding scale subcutaneous four times a day. :*qs * refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: primary - pancreatic pseudocyst/abscess - hyponatremia - seizure disorder secondary - history of anoxic brain injury - history of hemorrhagic pancreatitis - seizure disorder discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , it was a pleasure taking care of you during your hospitalization. you were transferred to hospital for continued work up of your fevers. the infectious disease and neurology specialists were consulted to help with your case. the infectious disease doctors were concerned that the enlarging pancreatic pseudocyst seen on the imaging from the other hospital was infected so you underwent a ct-guided drainage of the pseudocyst. this revealed pus which grew a bacteria called strep . you were initially treated with broad spectrum antibiotics that were then narrowed to a single , ceftriaxone. you will need to take this antibiotic for a prolonged time, for at least 5 weeks. a repeat ct scan revealed significant decrease in the size of the pseudocyst. at your follow up visit with infectious disease, they will help guide the . you had 2 seizures while you were on the floors. these were due to your sodium level being too low. you went to the icu and were treated with hypertonic saline and tablets and your sodium normalized and you had no more seizures. neurology did not change your medication regimen. you had a sinus tachycardia that we were not able to find a cause for. we had the cardiologists see you and they thought this may have been due to anemia. we gave you a blood transfusion, however your heart rate did not improve. we started a medication called metoprolol which did help control your heart rate. you were able to ambulate without symptoms. because of your nausea and vomiting, we started a medication called omeprazole to help with this. medication changes: started ceftriaxone 2gm q24 hours for 5 weeks - this will be adjusted by the infectious disease doctors as needed tablets 1 gm by mouth three times a day metoprolol succinate 25 mg by mouth once daily omeprazole 20mg by mouth once daily increased lantus to 42 units subcutaneously every morning humalog - per provided sliding scale decreased sertraline to 75mg by mouth daily . please follow-up with your scheduled appointments. you will need to make appointments to follow-up with your outpatient neurologist and endocrinologist. if you do not hear from ercp in the next 1 week, please call and make an appointment. followup instructions: ercp will be in touch with you to an appointment in the next two weeks. your scheduled appointments include: name: church, address: , , phone: appt: at 1pm infectious disease provider: , md phone: date/time: 10:30 department: cardiac services when: tuesday at 1 pm with: , md building: sc clinical ctr campus: east best parking: garage department: surgical specialties when: friday at 10:30 am with: , md building: campus: east best parking: garage dr. should follow up with the pending aldosterone and renin to evaluate for hypoaldosteronism. please call your endocrinologist and neurologist to make follow-up appointments. Procedure: Drainage of pancreatic cyst by catheter Central venous catheter placement with guidance Central venous catheter placement with guidance Diagnoses: Hyperpotassemia Anemia of other chronic disease Unspecified pleural effusion Abnormality of gait Nausea with vomiting Other specified cardiac dysrhythmias Anoxic brain damage Long-term (current) use of insulin Epilepsy, unspecified, without mention of intractable epilepsy Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Other disorders of neurohypophysis Acute pancreatitis Cyst and pseudocyst of pancreas