text:  1  Bronchiolitis obliterans organizing pneumonia  The video assisted thoracoscopic study at the outside hospital was consistent with bronchiolitis obliterans organizing pneumonia . The patient was continued on steroids throughout the course of her stay . This was changed to Solu-Medrol part way through the course due to her hematologic problems   see below . By discharge   she was returned to 40 mg of Prednisone q. day times one month to be followed by a slow taper . The patient &aposs bronchiolitis obliterans organizing pneumonia appeared to improve slowly throughout her hospital course   however on July 12   1998   after starting dialysis  see below    the patient desaturated and required supplemental oxygen . Repeat chest x-rays and chest CT scans appeared consistent with pulmonary edema from volume overload given her renal failure and eventually   the patient &aposs pulmonary status did improve after significant volume removal with dialysis for several weeks . At the time of her discharge   the patient was still requiring two liters of supplemental oxygen to maintain her oxygen saturations in the mid 90 . 2  Thrombotic thrombocytopenic purpura  The patient was initially admitted with platelet count of 28   hematocrit of 32   LDH of 496 with 2 schistocytes and 2 spherocytes on her smear . This was felt to be consistent with thrombotic thrombocytopenic purpura and on June 20   1998   she was started on daily plasma exchange which continued through July 27   1999 . She was also changed to intravenous Solu-Medrol 50 mg q. day which was changed back to 40 mg of Prednisone prior to discharge . Her platelet count initially rose to a maximum of 159 on July 3   1998   then they steadily fell to a low of 60 on July 20   1999 . Her LDH which peaked at 1255 decreased to the mid 200s   but remained elevated . She continued to have a few schistocytes on her smear   but it was much decreased . The patient also required red blood cell transfusions   approximately two units every seven to ten days to maintain her hematocrit . Eventually   her plasma exchange was tapered to a smaller and smaller dose each day and then discontinued altogether after July 27   1999 . After this   the patient &aposs platelet count rose to a maximum of 177 on discharge . It is felt that the patient &aposs thrombotic thrombocytopenic purpura has resolved . She will continue on her Prednisone for one month as above for the bronchiolitis obliterans organizing pneumonia with a very slow taper . 3  Renal  The patient presented in acute renal failure with a BUN of 101 and a creatinine of 3.7 . Throughout the month of June   she had a rising Potassium phosphate and increasing volume overload with decreasing response to diuretics and she was finally initiated on dialysis with ultrafiltration on July 12   1998 . The opinion of the Renal consult was that this was permanent and non-reversible renal failure since it did not improve with dialysis and the patient will continue on dialysis three times per week . She required approximately five liters of ultrafiltration fluid removal at each dialysis session due to her significant volume overload . During the course of her dialysis   she had a great improvement in her lower extremity edema and her oxygen saturation . 4  Infectious disease The patient had multiple line infections during her admission including a confirmed coag. negative Staphylococcus line infection with positive blood cultures on June 23   1998   July 4   1998   July 8   1998 and July 9   1998 . The patient eventually had a left subclavian Tesio catheter placed and a right brachial PICC line placed on July 10   1998 which remained patent and uninfected . She received a full three week course of Vancomycin and also received a three week course of Ceftazidime . In addition   she had a fungal urinary tract infection treated with Amphojel bladder irrigation   which was followed by a Klebsiella urinary tract infection for which she received Levofloxacin times fourteen days . She also received a fourteen day course of Acyclovir which was begun on June 21   1998 for perianal lesions consistent with herpes simplex virus . She was also on Fluconazole for some oral thrush which was inadvertently continued for a total of thirty days . The patient was also started on Bactrim one double strength tablet q.o.d. as prophylaxis for Pneumocystis carinii pneumonia while on her high dose steroids . 5  Rheumatology  The patient was admitted with a question of lupus given her ANA of 1640 although her rheumatoid factor and ANCA were negative . Unfortunately throughout her admission   we were unable to test any more titers since she was receiving daily plasma exchange . A repeat ANA   rheumatoid factor and ANCA may be repeated as an outpatient . FOLLOW-UP  1  The patient will follow-up with her primary care physician   Dr. Tamarg Study   in Arvus after she is discharged from rehabilitation . 2  The patient is being discharged to A Hospital where she will receive onsite hemodialysis three times per week on Monday   Wednesday and Friday . The nephrologist who will follow her there is Dr. Study . 3  The patient will continue to have her CBC   LDH   bilirubin   chem-7 and magnesium and calcium checked with each dialysis and the results will be faxed to Dr. Ian Zineisfreierm   the hematology attending at fax number 751-329-8840 . 4  The patient will eventually need a permanent dialysis fistula . The left subclavian Tesio which she has in place will last for several months in the mean time . She would like to arrange to have her fistula placed at Pre Health and the vascular surgeons there should be contacted regarding this . 5  The patient will need packed red blood cell transfusions with dialysis when her hematocrit falls below 26 . 6  The patient will continue her Prednisone at 40 mg p.o. q. day times one month  this was started on July 27   1999  and then she will begin a slow taper as guided by Pulmonary . 7  The patient has a follow-up appointment in the Pulmonary Clinic with Dr. Cedwi Stone at 336-2931 on August 30   1999 at 140 PM . 8  The patient has a follow-up appointment with Dr. Ian Zineisfreierm at the We Erthunt Hospital at 180-0455 on August 15   1999 at 1230 PM . MEDICATIONS ON DISCHARGE  1  Calcitriol 0.25 mcg p.o. q. day . 2  TUMS 1250 mg p.o. t.i.d. 3  Premarin 0.625 mg p.o. q. day . 4  Colace 100 mg p.o. b.i.d. 5  Humulin sliding scale q.a.c. and q.h.s. 6  Labetalol 400 mg p.o. t.i.d. 7  Omeprazole 20 mg p.o. q. day . 8  Serax 15 mg p.o. q.h.s. p.r.n. insomnia . 9  Prednisone 40 mg p.o. q. day times thirty days beginning on July 27   1999 to be followed by a slow taper as directed by the pulmonologist . 10  Metamucil one packet p.o. q. day . 11  Amlodipine 10 mg p.o. q. day . 12  Bactrim Double Strength one tablet p.o. q.o.d. 13  Nephrocaps one tablet p.o. q. day . 14  Epogen 1 000 units subcutaneously three times per week . 15  Iron sulfate 300 mg p.o. t.i.d. Dictated By  CHELA FYFENEIGH   M.D. NY5 Attending  LENNI E. NECESSARY   M.D. BE1 IZ845  6789 Batch  7665 Index No. YQGKGG4LST D  08  01  98 T  08  01  98 CC  CEDWI STONE   MD   BMH PULMONARY CLINIC TAMARG STUDY   MD   Port O