text:  Mother died at 51 metastatic BCA Father died at 36 aplastic anemia only child Physical Exam  T 100.0 bp 109  56 CVP 11 hr 113 rr 16 O2 95 on 3L NC mixed Quinn 82 genrl  in nad   resting comfortably heent  perrla  4->3 mm  bilaterally   blind in right visual field   eomi   dry mm   ? thrush neck  no bruits cv  rrr   no m  r  g   faint s1  s2 pulm  cta bilaterally abd  midline scar  from urostomy    nabs   soft   appears distended but patient denies   ostomy RLQ c  d   i   NT to palpation back  right flank urostomy tube   c  d   i   nt to palpation extr  no Gardner neuro  a   ox3   wiggles toes bilaterally   unable to lift LE   06-12 grip bilaterally w   UE   decrease sensation to soft touch in left UE and LE Pertinent Results  2014-11-29 0511PM WBC  23.5  RBC  3.81  HGB  9.4  HCT  29.2  MCV  77  MCH  24.6  MCHC  32.1 RDW  18.1 2014-11-29 0511PM NEUTS  93  BANDS  1 LYMPHS  0 MONOS  6 EOS  0 BASOS  0 ATYPS  0 METAS  0 MYELOS  0 2014-11-29 0511PM GLUCOSE  229 UREA N  25  CREAT  0.8 SODIUM  136 POTASSIUM  5.3  CHLORIDE  101 TOTAL CO2  17  ANION GAP  23  2014-11-29 0511PM LD  LDH   214 2014-11-29 0641PM LACTATE  1.4 2014-11-29 0511PM URINE COLOR  Straw APPEAR  Hazy SP Thibodeaux  1.008 2014-11-29 0511PM URINE BLOOD  LG NITRITE  NEG PROTEIN  TR GLUCOSE  NEG KETONE  NEG BILIRUBIN  NEG UROBILNGN  NEG PH  9.0 LEUK  SM 2014-11-29 0511PM URINE RBC  21-50 WBC  04-12 BACTERIA  MANY YEAST  NONE EPI  0-2 2014-11-29 0511PM URINE 3PHOSPHAT  OCC 2014-11-29 CT CAP  1. An 8 x 7 x 7 mm stone in the proximal right ureter with associated right hydronephrosis and inflammatory perinephric stranding . Additional smaller non-obstructing right renal stones . 2. Left renal stones without evidence of hydronephrosis . Ileal conduit is not well evaluated . 3. Right breast calcification . Correlation with mammography is suggested . . 2014-11-29 CXR  No evidence of pneumonia . . 2014-11-29 CT AP 2  with contrast   1. Eight mm right proximal ureteral stone with right-sided hydronephrosis and inflammatory stranding . Pyelonephritis of the left kidney without left sided hydronephrosis . No evidence of intraabdominal abscess or of diverticulitis . Bilateral round   hypodense renal lesions   too small to accurately characterize but likely representing cysts . 4. 1.4 cm hypodense lesion in right lobe of the liver is incompletely characterized . . 2014-11-30 CT CAP  Nephrostomy tube in the right kidney with an 8 mm right ureteric stone . 6 mm nonobstructing calculus in the left kidney . Calcified focus and a small hypodense lesion in the right lobe of the liver   incompletely characterized . Bibasilar and dependent atelectasis . . 2014-11-29 510 pm BLOOD CULTURE 2 .   FINAL REPORT 2014-12-04   AEROBIC BOTTLE  Final 2014-12-04   KLEBSIELLA PNEUMONIAE . IDENTIFICATION AND SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE . OF TWO COLONIAL MORPHOLOGIES . ANAEROBIC BOTTLE  Final 2014-12-04   REPORTED BY PHONE TO Robert BURGER 2014-11-30 1035A . KLEBSIELLA PNEUMONIAE . FINAL SENSITIVITIES . Trimethoprim  Sulfa sensitivity testing available on request . KLEBSIELLA PNEUMONIAE . FINAL SENSITIVITIES . Trimethoprim  Sulfa sensitivity testing available on request . 2ND STRAIN . SENSITIVITIES  MIC expressed in MCG  ML KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN  SULBACTAM- = >32 R = >32 R CEFAZOLIN  =4 S  =4 S CEFEPIME  =1 S  =1 S CEFTAZIDIME  =1 S  =1 S CEFTRIAXONE  =1 S  = 1 S CEFUROXIME 4 S 4 S CIPROFLOXACIN = >4 R = >4 R GENTAMICIN 8 I 8 I IMIPENEM  = 1 S  =1 S LEVOFLOXACIN = >8 R = >8 R MEROPENEM  =0.25 S  = 0.25 S PIPERACILLIN  TAZO  = 4 S  =4 S TOBRAMYCIN 4 S 8 I . 2014-11-30 150 pm URINE KIDNEY PERC. NEPH. .   FINAL REPORT 2014-12-03  FLUID CULTURE  Final 2014-12-03   Due to mixed bacterial types  >= 3 colony types  an abbreviated workup is performed appropriate to the isolates recovered from the site  including a screen for Pseudomonas aeruginosa   Staphylococcus aureus and beta streptococcus  . STAPH AUREUS COAG  . > 100 000 ORGANISMS  ML. . OF TWO COLONIAL MORPHOLOGIES . 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 . GRAM NEGATIVE ROD S  . > 100 000 ORGANISMS  ML. . OF TWO COLONIAL MORPHOLOGIES . SENSITIVITIES  MIC expressed in MCG  ML STAPH AUREUS COAG  | GENTAMICIN = >16 R LEVOFLOXACIN = >8 R NITROFURANTOIN  = 16 S OXACILLIN = >4 R PENICILLIN = >0.5 R TETRACYCLINE = >16 R VANCOMYCIN  =1 S . 2014-12-03 BLOOD CULTURE AEROBIC BOTTLE  PENDING  ANAEROBIC BOTTLE  PENDING 2014-12-03 BLOOD CULTURE AEROBIC BOTTLE  PENDING  ANAEROBIC BOTTLE  PENDING 2014-12-02 URINE URINE CULTURE  FINAL No Growth 2014-12-02 CATHETER TIP  IV WOUND CULTURE  FINAL No Growth 2014-12-02 BLOOD CULTURE AEROBIC BOTTLE  PENDING  ANAEROBIC BOTTLE  PENDING Brief Hospital Course  47 yo F w   h  o steroid-induced hyperglycemia   SLE w   h   o pericarditis   transverse myelitis w   paraplegia and neurogenic bladder s  p urostomy w   ileal conduit   h  o ureteropelvic stone and urosepsis   and h   o RLE DVT admitted 11-29 w   left pyelo and right 8 mm proximal ureteral stone w   right hydro s  p perc urostomy tube to relieve right hydro . .  GNR sepsis Upon admission   pt was febrile to 101.2 with U  A consistent with UTI . A CT abd showed 8mm obstructing stone   hydro with stranding consistent with pylonephritis . Her presentation was thought likely due to urosepsis given h  o foul smelling urine and in setting of stone w   hydro  pyelo by CT. The patient went to IR on 2014-11-30 given evidence of right hydronephrosis on imaging for decompression and drainage. Upon admission   she was treated with Vancomycin and Gentamycin and Flagyl . She was started on the MUST protocol with high dose steroids as well and a goal SVO2 >70 . She was hypoxic requiring 3L nasal cannula O2 . She subsequently developed hypotension with SBP in the 70s . She was transferred to the CMED where the patient was continued on the MUST protocol with goais of CVP 10-12   SVO2 greater than 70 . The patient was bolused with NS and did not required pressors . On the day after admission to the CMED   the patient was noted to have small oxygen requirement with 2L NC . Repeat imaging revealed evidence of mild pulmonary congestion which was thought to account for the patient s mild hypoxia . Given that the patient had been maintaining a MAP of 60 without fluids or pressors   her goal CVP was decreased to >8 to avoid fluid overload . The patient was continued on Vancomycin and Gentamycin while speciation and sensitivities were pending . Ciprofloxacin was added on 2014-12-01 for synergy when surveillance cultures were found to be growing again GNR . Gent and Cipro were then discontinued and changed to meropenem when blood culture sensitivities became available revealing GNR sensitive to Jacoby but resistant to both Gent and Cipro . Additionaly surveillance cultures were drawn daily and the patient was transferred back to the floor with no subsequent pressor requirement . Blood cltures from 11-30 grew KLEBSIELLA PNEUMONIAE and 12-01 grew KLEBSIELLA PNEUMONIAE and PROTEUS MIRABILIS both sensitive to the Meropenam which she had already been receiving . Urine cultures from 11-30 grew STAPH AUREUS COAG    and GRAM NEGATIVE RODS of two morphologies  not further speciated  . She defervesed by 12-02 and remained clinically stable with normal blood pressures until the day of discharge . At the time of discharge   blood cultures from 12-02 and 12-03 have no growth to date . She received a midline on 12-04 with a goal of 16 days of further antibiotic treatment with Meropenam  for a total of 3 weeks  upon discharge back to the nursing home where she lives . .  Right hydronephrosis  Given right sided hydronephrosis and GNR bactermeia   a percutaneous nephrostomy tube was placed by IR 2014-11-30 . The patient put out 1385 cc urine the day after placement   950 cc of which came from nephrostomy tube . The tube appeared to be functioning well   draining urine with occasional clot passage . Urology was notified about the clots and occasional blood tinged urine but they did not make any further recommendations . Cultures from urine drawn from the nephrostomy tube are currently growing > 100K GNR   possibly of two colony morphologies   speciation and sensitivity pending . .  Hct drop  On admission to hospital patient had Hct of 29.2 . In the setting of Right sublavian line placement as well as nephrostomy tube placement the patient was noted to have a drifting Hct   concerning for bleed   with nadir of 22.8 on 2014-12-01 . A CT abdomen was performed which did not demonstrate any retroperitoneal bleed . Hct stabilized to 24 for three days prior to discharge . This can be followed as an outpatient . Anemia workup revealed a picture of anemia of chronic disease  TIBC 225   B12 and Folate normal   Hapto 397   Ferritin 51   TRF 173   Iron 35  . .  Hypoxia The patient on admission was requiring 3 L NC in the setting of receiving 2L NS and chest film which demonstrated pulmonary congestion . The patient was not diuresed but allowed to auto-diurese any additional fluids and is currently with O2 sats 97-98 on room air . As her BP remained stable she did not receiving any standing fluids but was be bolused as appropriate for a MAP   60 or CVP   8 with careful monitoring of pulmonary status . Patient had an echocardiogram in 2012 which demonstrated an EF of 60-65 . her O2 requirement by discharge was 96 on room air with no SOB . .  Steroid-induced hyperglycemia  At home   the patient received metformin and SSI . The patient s metformin was held and she has been maintained on SSI qid while in the CMED . As the patient appeared to be clinically stable   her stress dose steroids were discontinued and the patient was changed back to her home dose of Prednisone 40mg PO qd for maintenance with anticipated decrease in her blood sugars . Her Metformin was re-added 2 days prior to discharge as well and fingerstick glucoses on the day of discharge were 93 and 156   respectively . .  Hypothyroidism  Repeat TSH and Free T4 were appropriate on current outpatient regimen. Patient was continued on Levothyroxine 75mcg po qd . .  H  o transverse myelitis  optic neuritis  On stress dose steroids originally given MUST protocol and sepsis   as patient clinically stabilized   she was changed back to home dose of Prednisone 40mg pO qd . .  SLE  Currently no sx of active disease . No manifestations of SLE during this admission . .  Osteoporosis  We continued actonel  vit D   Tums .  Capsular ossification We continued CMED CSRU gtt . .  FEN She had a low bicarb likely due to renal wasting but there is an anion gap present . Serum acetone was normal . We followed lactate while she was in the CMED which was normal . She was NPO periodically but maintained a normal diet prior to discharge . .  PPX  SQ Heparin during this admission   PPI .  Communication  patient .  Dispo  To nursing home for follow up with Dr. Hipp  urology  this coming Monday   12-08 at 130pm and with her PCP at the nursing home Medications on Admission  Home Meds  Ascorbic Acid 500 TID Cranberry Extract 425 BID Bisacodyl 10mg Senna Dephenhydramine 50mg prn loperamide prn famotidine 20mg KCL 20mg QD Metformin 1000 qd tums 1500 bid MVI Timolol 1 Drop BID 0.5 L CMED CSRU Synthroid 75 QD Compro 25mg pr Citrucel Vitamin D 50k Qmondays Oxazepam 15mg qhs tizamidine 8mg qhs actonel 35 qwed Diovan 80 qd prednisone 40 qd bactrim ds qmwf baclofen pump 2-3yrs Insulin SS . Meds on transfer Actonel 35 mg Oral qwednesdays Ascorbic Acid 500 mg PO TID Sodium Polystyrene Sulfonate 15 gm PO ONCE 11-29 @ 2201 Famotidine 20 mg PO DAILY Sulfameth  Trimethoprim DS 1 TAB PO QMOWEFR Gentamicin 80 mg IV Q8H Timolol Maleate 0.5 1 DROP OS BID Heparin 5000 UNIT SC TID Tizanidine HCl 8 mg PO QHS Hydrocortisone Na Succ. 100 mg IV Q8H 11-30 @ 0906 Valsartan 80 mg PO DAILY Insulin SC  per Insulin Flowsheet  Vancomycin HCl 1000 mg IV Q 12H Levothyroxine Sodium 75 mcg PO DAILY Vitamin D 50 000 UNIT PO QWEDNESDAYS Discharge Disposition  Extended Care Discharge Diagnosis  GNR Sepsis  Steroid induced hyperglycemia  Hydronephrosis  SLE Discharge Condition  Stable Discharge Instructions  Pls take all meds as prescribed . Call your doctor immediately if any new symptoms develop including fevers   rash   increase in bloody urine in nephrostomy or urostomy bags   etc . Follow up appointments listed below . Followup Instructions  With Dr. Vivian Hansen   UMass Memorial Medical Center   3rd floor Morris on Monday 12-08 at @ 130pm  you also have an appointment scheduled with Dr. Hipp for 01-14  . . Provider  Sheena Phone  361-438-6334 Date  Time  2015-01-07 830 Colleen Thomas MD 80-548 Completed by  Edward James MD 50-497 2014-12-05 @ 1042 Signed electronically by  DR. Ronald Z. Thome on