Medical Text: Admission Date:  [**2142-11-30**]              Discharge Date:   [**2142-12-10**]

Date of Birth:  [**2084-5-2**]             Sex:   M

Service: MEDICINE

Allergies:
Percocet / Bactrim Ds / Lisinopril

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 25925**] is a 58 yo m w/ multiple sclerosis and seizure
disorder who presented to an OSH for delusions and AMS x 2 days.
At OSH, he was noted to have a Na of 124. He does have a history
of hyponatremia; he had a Na of 117 in [**2-27**] but had been in the
mid 130s since then. He has seen nephrology. At the OSH, he had
an approx 45sec generalized tonic clonic seizure, received 1mg
Ativan, and transferred to the ED at [**Hospital1 18**]. He also has a
history of seizures especially in the setting of infection and
hyponatremia. It is unclear if he has had seizures without an
inciting event. He is currently being weaned off of Keppra and
Gabapentin and is being started on Tegretol. In the ER, his VS
were: 97.5; 189/105; 78; 16; 95% 3L. He was given 2L of NS.
Given that he has had AMS in the setting of infection and is
known to have chronic UTIs [**12-24**] indwelling suprapubic catheter
and neurogenic bladder, blood and urine cultures were obtained
as well as a CXR. He had a urine culture from [**11-28**] that grew
pseudomonas and his CXR showed a possible infiltrate and he was
treated with vancomycin and cefepime. A head CT was negative.

Past Medical History:
MS - since [**2119**], progressive, quadriplegic, neurogenic bladder
with suprapubic catheter, restrictive PFT's
History of Aspiration PNAs
Esophageal Ulcer - [**12-24**] NSAIDs, [**2139**], small bowel bx negative
Recurrent UTIs
CHF (EF > 65% with moderate LVH in '[**39**])
HTN
Legally Blind

Social History:
He is married 32 years and lives with his wife at home. He has
three children and three grandchildren. He was a professor [**First Name (Titles) **] [**Last Name (Titles) 25949**] engineering at [**University/College 25932**], but
retired on disability after the [**2128**] spring semester due to his

MS. [**Name13 (STitle) **] is wheelchair-bound. He denies tobacco, alcohol, and
recreational drug use. Has personal care assistant.

Family History:
Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother

has diabetes.

Physical Exam:
General: 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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2142-11-29**] 10:47PM BLOOD WBC-6.4 RBC-3.99*# Hgb-11.8*# Hct-33.1*
MCV-83# MCH-29.7 MCHC-35.7* RDW-15.0 Plt Ct-235#
[**2142-12-10**] 05:50AM BLOOD WBC-8.8 RBC-3.54* Hgb-10.8* Hct-31.0*
MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-424

[**2142-12-7**] 05:50AM BLOOD PT-13.6* PTT-34.1 INR(PT)-1.2*

[**2142-11-29**] 10:47PM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-126*
K-4.5 Cl-88* HCO3-29 AnGap-14
[**2142-11-30**] 06:58AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-125*
K-4.6 Cl-90* HCO3-28 AnGap-12
[**2142-11-30**] 12:40PM BLOOD Na-128*
[**2142-11-30**] 09:45PM BLOOD Na-127*
[**2142-12-1**] 07:40AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-131*
K-4.0 Cl-93* HCO3-29 AnGap-13
[**2142-12-1**] 03:00PM BLOOD Glucose-101 UreaN-16 Creat-0.8 Na-131*
K-4.5 Cl-94* HCO3-30 AnGap-12
[**2142-12-2**] 05:45AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-133
K-4.6 Cl-95* HCO3-28 AnGap-15
[**2142-12-2**] 04:10PM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-131*
K-4.9 Cl-93* HCO3-27 AnGap-16
[**2142-12-3**] 06:20AM BLOOD Glucose-121* UreaN-21* Creat-1.2 Na-131*
K-4.3 Cl-93* HCO3-28 AnGap-14
[**2142-12-3**] 05:40PM BLOOD Glucose-115* UreaN-25* Creat-1.3* Na-134
K-4.4 Cl-96 HCO3-27 AnGap-15
[**2142-12-4**] 07:18AM BLOOD Glucose-101 UreaN-23* Creat-0.8 Na-135
K-4.0 Cl-98 HCO3-27 AnGap-14
[**2142-12-5**] 05:30AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-135
K-3.9 Cl-96 HCO3-26 AnGap-17
[**2142-12-6**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-134
K-4.2 Cl-97 HCO3-28 AnGap-13
[**2142-12-7**] 05:50AM BLOOD Glucose-102 UreaN-21* Creat-0.8 Na-137
K-4.2 Cl-97 HCO3-26 AnGap-18
[**2142-12-8**] 07:00AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-136
K-3.9 Cl-99 HCO3-27 AnGap-14
[**2142-12-9**] 06:30AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-140
K-4.0 Cl-101 HCO3-28 AnGap-15
[**2142-12-10**] 05:50AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-140
K-4.5 Cl-102 HCO3-26 AnGap-17

[**2142-11-29**] 10:47PM BLOOD Osmolal-260*
[**2142-11-30**] 12:40PM BLOOD Osmolal-264*

[**2142-12-8**] 07:00AM BLOOD ALT-23 AST-16 LD(LDH)-213 AlkPhos-87
TotBili-0.2

[**2142-12-10**] 05:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.4

U/A [**11-28**]: nit +, LE +, WBC 55, RBC 6, Epi 1, bact few
U/A [**11-29**]: sm bld, 100 prot/gluc; WBC [**1-24**], RBC [**1-24**], Epi [**1-24**], bact
mod
U/A [**12-2**]: sm LE, WBC 10, RBC 2, Epi 1, bact none
U/A [**12-5**]: 30 prot, 10 ket, lg LE; WBC 99, RBC 11, Epi 1, bact
few
U/A [**12-6**]: 30 prot, mod LE; WBC 22, RBC 8, Epi 3, bact none
U/A [**12-8**]: neg leuk

CULTURES:
BCx [**11-29**] x2: neg
BCx [**12-2**] x2: neg
UCx [**11-28**]:  PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML
UCx [**11-29**] pseudomonas
UCx [**12-2**] yeast
Ucx [**12-5**] neg
Ucx [**12-6**] yeast
Ucx [**12-8**] neg

c.diff neg x 2

- CXR from [**12-2**]:  Patchy opacity at left base again noted, but
the significance in the setting of low inspiratory volumes is
uncertain.
- CTA from [**12-2**]: No PE. Scattered patchy ground-glass opacities
may represent expiratory state with air trapping.
- Renal u/s from [**12-2**]: No evidence of abscess, hydronephrosis or
mass
- abd xray from [**12-3**]: non-specific bowel gas pattern, stool
throughout colon, no free air
- abd xray from [**12-4**]: Stool- and air-filled loops of large and
small bowel consistent with ileus.
- Liver u/s from [**12-5**]: Hypoechoic right hepatic mass, measuring
up to 4.2 cm in size
- CT abd: prelim read: Arterially enhancing liver lesion cannot
be fully characterized, may represent adenoma, FNH, or less
likely HCC.


Brief Hospital Course:
58 yo male w/ progressive multiple sclerosis was admitted for
AMS and seizure after having a 45s GTC at the OSH that responded
to 1mg Ativan.  He had a negative head CT but was found to have
a Na level of 126.  He has been hyponatremic in the past and
this has often caused changes in his mental status.  In the ED,
he was treated with 2L NS for concern of hypovolemic
hyponatremia.  At that time, his urine osm was 423 and serum osm
was 263. He also had a CXR and there was prelim concern for
pneumonia which can cause an ADH like effect (the final read was
neagtive).  Neurology was consulted for his AMS and seizure and
they felt that his hyponatremia was likely related to recent
initiation of carbamezapine for sensory illusions.
Carbamezapine has a known ADH like effect and can cause
hyponatremia.  Following discontinuation of carbamezapine along
with fluid restriction, his Na increased.  After several days,
the pt appeared slightly dehydrated so his fluid restriction was
lifted. By time of discharge, his serum Na was 140.
.
In the past, his seizures have been instigated by an underlying
infection. However, upon admission he was afebrile and did not
have a leukocystosis.  The most likely source was either
pneumonia or a UTI.  He has a suprapubic catheter [**12-24**] neurogenic
bladder and on the day prior to admission, he had a urine sample
that grew pseudomonas, a bacteria he has had in the past.  He
has also had several pneumonias in the past, most likely [**12-24**]
frequent aspirations and his first CXR was concerning for lung
infiltrate.  He was treated with one dose of vancomycin and
cefepime for pneumonia.  Ultimately, repeat CXR and a CTA were
both negative for pneumonia.
.
Because of his pseudomonal bacteriuria, he was started on
ciprofloxacin. A urine culture drawn prior to abx inititian also
grew pseudomonas.  Because he was afebrile and did not have a
leukocytosis and there was thought that it may actually have
been colonization as opposed to infection.  However, he was
treated with a full course of cipro for a complicated UTI.  His
catheter was changed and all other cultures remained negative.

.
On admission, the pt was afebrile and hypertensive to 180-200.
However, shortly after arriving on the floor, he had an episode
of hypotension down to the 70's systolic.  During this time he
was mentating well, he did not have any complaints, denied chest
pain, headache, and visual changes.  IVFs were given, however
the hypotension did not initially respond, however came up
eventually prior to getting to the ICU.  This labile blood
pressure was most likely secondary to the patient's autonomic
dysfunction secondary to his SPMS. Other considerations were
infection or possible sepsis, however the patient was continued
to be afebrile. Blood and urine cultures were negative. He was
monitored in the ICU for 24 hours with stable swings in BP which
were asymptomatic and consistent with autonomic dysfunction.
Changed clonidine dosing from 0.2mg [**Hospital1 **] to 0.1mg TID.
Maintained other blood pressure medications at home doses.
.
The next day, he was transferred out of the MICU and returned to
the floor.  Shortly after arrival, he developed a fever.  More
blood and urine cultures were sent and all were negative.
Pneumonia had been ruled out and his UTI was being treated with
a medication that was appropriate per sensitivities.  He had a
CTA which was negative for PE.  However, he was started on
meropenem and was treated for 2 days.  He was still slightly
febrile but his meropenem was discontinued for concern of drug
fever.  He defervesced without any further treatment.
.
However, his mental status continued to fluctuate despite being
afebrile, no obvious source of infection, and he was eunatremic.
 He was occasionally aggressive and would say that he was being
murdered or kidnapped.  Neurology was reconsulted but did not
feel that his symptoms were related to the keppra and they did
not think he was having subclinical seizures.  He continued to
have repetitive shaking moves of his head but he was conscious
and able to speak during these episodes. Also, despite the
Keppra, he continued to have sensory illusions, mostly centered
around the feeling of having a bowel movement (when he actually
was not).
.
During the work up for a source of infection and source of AMS,
he had a CTA which revealed a liver lesion.  He had an
ultrasound and a multiphase liver CT to further describe the
lesion because he cannot have an MRI [**12-24**] an implanted baclofen
pump.   Mr [**Known lastname 25925**] and his family decided to not biopsy the lesion
at this time but it was not ruled out completely for malignancy,
although unlikely.  During this work up he also had KUB that was
concerning for ileus but he continued to have BMs so he was kept
on a regular diet.
.
Prior to discharge, his mental status had not completely
returned to baseline but he was alert and oriented x 3 and was
no longer aggressive towards staff.  No definite etiology was
elucidated and it was hypothesized that this could be a result
of the progression of his established disease.

Medications on Admission:
BACLOFEN 2,000 mcg/mL Kit -pump
BRIMONIDINE Dosage uncertain
CARVEDILOL - 25 mg Tablet [**Hospital1 **]
CARBAMEZAPINE - 100mg [**Hospital1 **]
CLONIDINE - 0.2 mg Tablet [**Hospital1 **]
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream tid
FENTANYL - 12 mcg/hour Patch 72 hr
FUROSEMIDE - 40 mg Tablet qd
IPRATROPIUM-ALBUTEROL prn
LACTULOSE prn
MINOCYCLINE - 100 mg Tablet [**Hospital1 **]
MODAFINIL [PROVIGIL] 50 [**Hospital1 **]
OMEPRAZOLE 20 [**Hospital1 **]
OXYBUTYNIN CHLORIDE - 15 mg qhs
SIMVASTATIN - 40 mg qd
TRAVOPROST1 drop L eye once a day
ACETAMINOPHEN prn
ASCORBIC ACID 500 [**Hospital1 **]
BISACODYL hs
CALCIUM 500 mg Tid
CRANBERRY 475 mg Capsule [**Hospital1 **]
ERGOCALCIFEROL (VITAMIN D2)400 [**Hospital1 **]
MINERAL OIL prn
OMEGA-3 FATTY ACIDS [**Hospital1 **]
PSYLLIUM [METAMUCIL] prn
SENNA - 8.6 mg Tablet prn


Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Oxybutynin Chloride 5 mg Tablet Sig: Three (3) Tablet PO QHS
(once a day (at bedtime)).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. Simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: through [**2142-12-13**].
16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
18. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
19. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) inh
Inhalation twice a day as needed.
20. TRAVATAN Z 0.004 % Drops Sig: One (1)  Ophthalmic once a
day: To Left eye.
21. Cranberry 475 mg Capsule Sig: One (1) Capsule PO twice a
day.
22. Omega-3 Fatty Acids     Capsule Sig: One (1) Capsule PO
twice a day.
23. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.

The patient has an allergy listed to ACE Inhibitors, and was
therefore not discharged on an ACE Inhibitor. This will be
communicated to PCP.


Discharge Disposition:
Home With Service

Facility:
[**Hospital **] Home Health Care

Discharge Diagnosis:
1. Multiple Sclerosis
2. Urinary Tract Infection, complicated
3. Hyponatremia
.
Secondary:
1. Chronic Diastolic CHF


Discharge Condition:
Stable vital signs.


Discharge Instructions:
You were admitted with altered mental status and found to have
low sodium and a urinary tract infection. You were started on
antibiotics for your urinary tract infection (cipro) to complete
a 2 week course. Your sodium corrected after adjusting your
medications and reducing your water intake.
.
You were found to have an abnormality in your liver. You had a
CT scan and the results are pending final interpretation. We
have provided a phone number below so that you can schedule an
appointment in [**Hospital **] clinic. It may be necessary to reimage the
liver or take a biopsy of the lesion seen on CT scan.
.
Your medications have changed. You were switched from tegratol
to keppra. Please review your most recent medication list and
take only these medications, and discard any old medications not
on this list.
.
Please return to the hospital if you develop fevers, chills, or
worsening symptoms.

Followup Instructions:
1. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2143-1-8**] 1:30
.
2. [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-1-15**]
4:00
.
3. [**Hospital **] CLINIC at [**Hospital1 18**]: ([**Telephone/Fax (1) 2233**]



Completed by:[**2142-12-13**]
ICD9 Codes: 5990, 2761, 5849, 4280, 2930, 4019