tokens: Admission Date : 2019-01-19 Discharge Date : 2019-01-24 Date of Birth : 1981-03-17 Sex : M Service : MEDICINE Allergies : Patient recorded as having No Known Allergies to Drugs Attending : Antonio I Staples , M.D. Chief Complaint : nausea and vomiting Major Surgical or Invasive Procedure : 01-23 PORT line removal . 01-23 PICC placement . 01-24 PICC removal . History of Present Illness : This is a 37 y/o male patient with PMH Type I DM , HTN , gastroparesis , ESRD on HD ( last in 12/26 per patient ) who presents to CMED CCU with hypertensive urgency unable from the Larry . The patient early this morning to the Ruthie with his usual nausea , vomiting , abdominal pain and was found to be hypertensive to 256/110 , HR 102 , T 99.2 , RR 22 , 92% RA . History is difficult to obtain from patient d/t somnolence and lack of desire to participate in interview , but per Frank note he was diaphoretic and ' writing in pain ', vomiting clear substance . He was given ativan a total of 4 mg of ativan , 6 mg of dilaudid , labetolol 20 mg IV x 1 and hydralazine 10 mg IV x 1 without good response ( 200/99 ). He recieved 2L NS and was started on labetolol gtt and BP decreased to 161/79 . Tranferred to CMED CCU for further management while on labetolol gtt . Of note , the patient is admitted to hospital 3 times every month for similar complaints with last admission 1/20-2/1/07 . At that time BP was attributed to abdominal pain and inability to take PO meds d/t nausea / vomiting . Also had labile blood sugars with repeated episodes of hypoglycemia , and Strickland recommended sugars in the range of 150-200 . He eloped prior to formal discharge when his FS was found to be critically high - recommended to patient that he stay for repeat , but left AMA without signing any forms . Upon transfer to the CMED CCU the patient appears somewhat uncomfortable , reporting nausea and abdominal pain , but when questioned he was unable / unwilling to participate in HPI or exam d/t sleepiness . He denied CP , SOB , HA , vision changes , neck stiffness , dysuria , or other symptoms . In the CMED CCU he became hypotensive to SBP 80 s. Labetalol was stopped and he received a 500 cc fluid bolus and his blood pressure rose to SBP 90 s. Cardiac and infectious sources of hypotension were considered , but cardiac enzymes were not changed from prior studies and he had no localizing signs of infection ; blood cultures were sent and a ultrasound of the L arm AVF ordered to rule out abscess at the site . He received a partial HD session , limited by hypotension . Over night , his blood pressure trended up to 130 s systolic . He was restarted on his home blood pressure regimen . Renal consult team saw him 2019-01-20 and plan to next dialyze him on 2019-01-21 . He was to be called out to the medical floor on 2019-01-20 but became somnolent after receiving pain and anti-nausea meds , so he stayed in the ICU for closer monitoring of respiratory status , which spontaneously improved . His blood sugar at 10 pm was low at 22 and he was disoriented , which resolved with two glasses of juice ; he did not receive his standing dose of NPH that evening . Blood cultures returned positive with GPC in pairs and clusters , so a TTE and surveillance cultures were ordered and vancomycin was started . He was then called out to the medical floor on 01-21 . Past Medical History : 1. DM type I 2. ESRD on hemodialysis started 2017-01-07 on Tu , Th , Sat 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency , gastroparesis , and orthostatic hypotension . 4. History of esophageal erosion , MW tear 5. CAD with 1-vessel disease ( 50% stenosis D1 in 2014-06-07 ), normal stress 2015-10-07 6. hx of Foot Ulcer 7. h/o clot in AV graft x2 ( March and 2018-07-07 ) Social History : Denies alcohol or tobacco use . Endorses occassional marijuana use . Lives with his Carney Hospital mother and their three children . Family History : His father recently died of ESRD and diabetes . His mother is in her 50 s and has hypertension . He has two sisters , one with diabetes , and six brothers , one with diabetes . Physical Exam : Vitals : 97.4 , 164/90 , 102 , 10 , 97% 4L General : sleepy , arouses to voice but limited participation with physical exam HEENT : PERRL , left pupil smaller than right , pt will not participate in EOMI , sclera anicteric , MM dry , No OP lesions Neck : Supple , no JVD CV : RRR , nl S1 , S2 , 2/6 systolic murmur at LUSB Lungs : CTAB post Chest : HD line in place without erythema Abd : Soft , ND , nontender , + BS , no guarding , no rebound , multiple well healed scars Ext : no c/c/e , left arm with fistula with good thrill Skin : no rashes Brief Hospital Course : Pt admitted to medical floor in hemodynamically stable condition without specific complaints . # hypertensive urgency : Upon presentation it was unclear when last time was that patient took meds , but hypertension likely d/t inability to take meds in setting of N/V . Also contribution of autonomic dysfunction . No evidence of active end organ damage . Pt was treated with labetalol gtt in CMED CCU which was weaned off on 01-20 . carduac enzymes mildly elevated , felt 02-08 demand ischemia in setting of hypertensive urgency , CK and MB trended Mcewen at time of admission to medical floor . Pt 's hypertensive urgency was resolved upon admission to the medical floor . His SBP s ranged 140 s- 170 s . He was restarted on his home regimen of antihypertensives without difficulty ( metoprolol 75 tid , clonidine patch and oral , nifedipine 30 SR q daily ). he was discharged home with change in his regimen . # bacteremia : pt with 2/4 bottles coag neg staph on 01-19 and again on 01-20 . PORT was felt most likely source , and pt has had at least 2 sets of + blood cultures since it was placed . TTE was obtained which was not concerning for endocarditis . pt without stigmata of SBE . ID consult obtained which recommended removal of PORT , which was taken out on 01-23 . Pt will compelete a 2 week course of vancomycin at hemodialysis , which has been arranged by renal service . A PICC was breifly placed , however removed as it is unclear if pt can reliably flush this . PORT will be replaced on 2019-02-11 per IR ( Dr. Welsh placed last PORT , then removed it on 01-23 ), ordered placed in OMR . Indication : diabetic gastropathy causing inability to toleral oral antihypertensive medication prompting repeated Donald presentation for hypertensive urgency . Pt with surveillance cultures and port tip cultures showing NGTD on 01-24 , he will have futher surveillance cultures drawn at hemodialysis and followed by his nephrologist . # n/v/ abdominal pain : pt with multiple admissions with similar complaints , etiology 02-08 gastroparesis , improves considerably with ativan , dilaudid , reglan , pt was tolerating PO meds / diet at time of admission to medical service and was restarted on oral reglan . # DMI : Pt on sliding scale as inpatient and taking NPH 2 units BID at home . pt with two episodes of hypoglycemia ( FSBS 22 and 27 ), etiology unclear , pt followed by Strickland , who recommend no changes to current insulin regimen . will discharge pt with instructions to continue NPH 2 UNITS BID as Frederick Tracey recs . # CAD - pt denied cp / sob throughout hospitalization . Troponins rose at admission , however CK and MB trending Mcewen wat time of admission to medical service . Etiology felt most likely demand ischemia in setting of original hypertensive urgency with persistent elevation of trop 02-08 ESRD . Pt was continued on aspirin , metoprolol , nifedipine . # ESRD : etiology likely 02-08 DM and HTN , pt tolerating HD well , and underwent dialysis without difficulty on 01-24 . pt will be discharged home with plan to continue current dialysis schedule ( Tue / Th / Sat ). In addition pt will be given vancomycin at dialysis x 2 week course ( last day 2019-02-05 ) given his PORT line infection . He will have levels drawn at dialysis and be dosed with vancomycin as appropriate . Plan is for surveillance cultures to be drawn at dialysis . If negative , pt is scheduled for presumptively replacement of PORT on 2019-02-11 with interventional radiology ( dr. Arevalo ). Pt continued on home regimen of calcium acetate 667 mg , 3 capsules TID . # AV fistula : pt with h/o numerous clots in AV fistula . No signs of infection presently , and tolerating dialysis without difficulty . Pt was subtherapeuticon INR on admission , thus treated with heparin gtt . coumadin held on 01-22 for PORT removal , and restarted on 01-24 . Pt discharged with instructions to continue coumadin 1.5 mg po q daily with goal INR 02-09 . # DISPO : pt discharged home on 01-24 with instructions to complete 2 week course of vancomycin at hemodialysis for his PORT line infection . an appointment was made with interventional radiology on 2019-02-11 to replace his PORT , under the assumption that his surveillance cultures from dialysis remain negative . discussed this plan with renal service ( Anthony Mcknight ) who will communicate with pt 's outpatient dialysis service . Medications on Admission : Metoclopramide 10 mg PO Q6 Metoprolol Tartrate 75 mg PO TID Calcium Acetate 1340 mg tid with meals Anzemet 12.5 IV prn Prochlorperazine 10 mg IV Q6H prn Ativan 1 mg PO Q6H prn Dilaudid 4mg PO Q3-4H prn Insulin NPH 2 units Subcutaneous twice a day . Clonidine 0.3 mg / 24 hr Patch Weekly Transdermal QTHUR Clonidine 0.2 mg PO TID Prochlorperazine 10 mg q 6 h Coumadin 1.5 mg PO QHS Nifedipine 30 SR mg PO QD Bisacodyl prn Protonix 40 QD Discharge Medications : 1. Metoclopramide 10 mg Tablet Sig : One ( 1 ) Tablet PO Q6H ( every 6 hours ). 2. Metoprolol Tartrate 25 mg Tablet Sig : Three ( 3 ) Tablet PO TID ( 3 times a day ). 3. Calcium Acetate 667 mg Capsule Sig : Three ( 3 ) Capsule PO TID W/ MEALS ( 3 TIMES A DAY WITH MEALS ). 4. Ativan 1 mg Tablet Sig : One ( 1 ) Tablet PO q6h prn . 5. Dilaudid 4 mg Tablet Sig : One ( 1 ) Tablet PO q3-4hr prn . 6. Clonidine 0.3 mg / 24 hr Patch Weekly Sig : One ( 1 ) Patch Weekly Transdermal Q WED ( every Wednesday ). 7. Clonidine 0.2 mg Tablet Sig : One ( 1 ) Tablet PO TID ( 3 times a day ). 8. Warfarin 1 mg Tablet Sig : 1.5 Tablets PO DAILY ( Daily ). 9. Nifedipine 30 mg Tablet Sustained Release Sig : One ( 1 ) Tablet Sustained Release PO DAILY ( Daily ). 10. Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : One ( 1 ) Tablet , Delayed Release ( E.C. ) PO Q24H ( every 24 hours ). 11. Bisacodyl 5 mg Tablet Sig : One ( 1 ) Tablet PO once a day as needed for constipation . 12. Vancomycin in Dextrose 1 g / 200 mL Piggyback Sig : One ( 1 ) Intravenous QHD ( each hemodialysis ): 2 week course to be given at dialysis , last day 2019-02-05 . Disp :* qs * Refills :* 2 * 13. Aspirin 81 mg Tablet Sig : One ( 1 ) Tablet PO once a day . 14. Humalog 100 unit / mL Solution Sig : USE AS DIRECTED Subcutaneous four times a day : please use attached sliding scale . Disp :* qs * Refills :* 2 * 15. Insulin NPH Human Recomb 100 unit / mL Suspension Sig : 2 UNITS Subcutaneous twice a day . Disp :* qs * Refills :* 2 * Discharge Disposition : Home Discharge Diagnosis : primary : bacteremia 02-08 PORT line infection hypertensive urgency diabetic gastropathy Discharge Condition : stable . Discharge Instructions : please continue to take all of your medications as prescribed . you were started on a 2 week course of vancomycin to be given at hemodialysis for your line infection . you will have your PORT replaced after 2 weeks of antibiotics if your blood cultures remain negative . if you have recurrent fevers , chills , naseau , vomitting , chest pain , shortness of breath , or other worrisome symptoms , please contact your primary care physician or the emergency department . Followup Instructions : please follow up with your primary care doctor within 4 weeks . please follow-up with your dialysis physician regarding replacing your PORT . please follow-up with dr. Lillian becker in gastroenterology within 1-2 weeks , an appointment has been made for on you 2019-02-11 at 3PM . ( 447 ) 671-2034 ( Caldwell building , 1st floor , 1718 S. Sixth Blvd. ). upon arriving home please contact the King and arrange to be seen within 1-2 weeks . Adam Ruth MD 61-358 Completed by : Elwood Edmond MD 68-884 2019-01-31 @ 1141 Signed electronically by : DR. Pamula Pugh on : Russell 2019-01-31 12:12 PM ( End of Report )