LABORATORY DATA: On admission, the patient’s CBC showed normal white count, low H and H with MCV of 101, and platelet count was normal indicating macrocytic anemia. By discharge, the patient’s white count was 8.9, hemoglobin was 8.8, hematocrit 26.7, and platelet count was 230,000. PT/INR and PTT were normal. Chemistry profile showed, on admission, an elevated sodium at 146, uncontrolled blood sugar at 392, BUN 99, and creatinine of 3.2. AST, ALT, and alkaline phosphatase levels were all normal. By discharge, the patient’s chemistry profile showed a sodium of 136, BUN is down to 51 with a creatinine of 1.3. AST, ALT, and alkaline phosphatase levels were normal. The patient’s magnesium levels were normal. The patient did have a few episodes of hyperglycemia during her hospital course, probably secondary to IV and p.o. steroids. The patient’s cardiac enzymes were normal. She had a BNP on admission that was 186, repeated a few days later and it was 372. The patient also had a urinalysis, as stated earlier, that was abnormal, Candida albicans. The patient’s blood cultures showed no growth. The patient had no other diagnostic or invasive interventions during this hospital course.
The patient had a venous Doppler of bilateral lower extremities secondary to severe edema, showed no deep vein thrombosis. The patient also had a chest x-ray on admission that showed right central line placement, slight infiltrate within the left lung base, as well as cardiomegaly with tortuous and ectatic thoracic aorta. The patient had a repeat chest x-ray a few days prior to discharge that showed cardiomegaly. No interval change, no left effusion or left lower infiltrate.
LABORATORY DATA: On admission showed a CBC that was within normal limits. His white count was normal at 8.5. By discharge, his white count was 6.5, his hemoglobin 11.8, his hematocrit was 32.8, his platelet count was 527. PT/INR at the time of discharge was 22.4, his INR was 1.95. His chemistry profile on admission showed some slight abnormalities, as CO2 was 20. His BUN was 44. His creatinine was 1.3. TSH was normal. On discharge, his chemistry profile was unremarkable except for a slightly elevated glucose of 129. The patient is diabetic. The patient also had some cardiac enzymes on admission that were negative. He had a BNP that was 209. Urinalysis was negative. He had occult blood stools that were negative x2 and he had a urine culture that showed no growth. His blood cultures also showed no growth.
The patient also had an ultrasound of his kidneys during the stay that showed a single right kidney, identified without hydronephrosis. At the time, the patient had complaints of some dysuria as well as some retention. The patient also had a chest x-ray that showed bilateral pleural effusion, bibasilar opacities suggestive of atelectasis or infiltrates.
LABORATORY DATA: Serology studies showed on admission that the patient’s CBC was slightly abnormal. His white count was elevated at 13.3 and H and H and platelet count were normal. By discharge, the patient’s white count was 9.3, his hemoglobin was 11.9, his hematocrit was 35.5, platelet count was 243,000, and MCV was 89.6. He does have anemia of chronic disease and was on Aranesp during his hospital stay. PT, PTT, and INR normal. Chemistry profile on admission was also abnormal indicating mild hyperkalemia as well as mild hyponatremia. By discharge, the patient’s chemistry profile was within normal limits except for elevated BUN of 38 with a creatinine of 1.7 secondary to his chronic renal failure. The rest of his chemistry profile was within normal limits. Magnesium levels were normal. His CK enzymes and troponins were, I believe, normal. His CK-MB actually was elevated, but he had normal troponins. BNP was 103 on admission, repeat was 65. TIBC 358 with a ferritin level of 265. Urinalysis on admission was negative for any bacteria or pyuria. MRSA screens were negative even though the patient had a history of MRSA and no other studies were performed.
Nuclear medicine renal scan showed split renal function, 45 left and 55 right. Otherwise, fairly symmetrically diminished perfusion consistent with renal disease. No evidence of obstructive uropathy. The patient had a chest x-ray on admission that showed slightly improved CHF and no active pulmonary disease.
LABORATORY DATA: White count 12.9, hemoglobin 11.2, hematocrit 34.8, platelets 365, 53% segs, 13 bands, 11 lymphs, 22% monos. Absolute monocyte count was elevated at 2.8. White count was as high as 23.9 previously. PT/INR and PTT essentially unremarkable. Alkaline phosphatase was 258, slightly elevated. Sodium 144, potassium 3.6, chloride 108, CO2 of 26, BUN 22, creatinine was down to 1.7. LFTs were normal. Serial blood sugars were obtained during the hospital stay. Lipase elevated at 274 and 241. This was as high as 290 and 236 previously. Total iron binding capacity 245, unconjugated iron binding capacity 218. Iron level 24. B12 of 280, folate 11.8, and haptoglobin 376. B-type natriuretic peptide was 426. CK-MB and troponins were negative. Urine; trace albumin, trace leukocyte esterase. Stool for occult blood was negative. Cultures on the chart negative.
Venous Doppler of the lower extremities revealed no evidence of DVT. Echocardiogram: Mild to moderate concentric left ventricular hypertrophy with normal leaflet size and function with normal systolic function, left ventricular diastolic dysfunction, however, and trace mitral regurgitation. EKG: Sinus rhythm, low voltage. The patient underwent fine needle aspiration with guidance with successful ultrasound-guided drainage, loculated small pocket of fluid adjacent to the anterior abdominal wall, represented purulent material. Ultrasound of the gallbladder: Pancreas is not enlarged. It has heterogeneous echotexture, nonspecific. Exophytic cyst along the right lobe of the liver was seen on prior CT. No evidence of gallstone or definite right renal stone. Minimal right perirenal fluid and a small fluid collection in the right mid abdomen measuring 4.4 x 4.6 x 1.4. CT of the abdomen limited with small fluid accumulation in the right mid abdomen measuring 1.4 x 2.6, probable liver cyst. Also, possible partial small bowel obstruction, distal ileum, and there is some fecal material in the colon. CT pelvis: Low-grade partial small bowel obstruction.
DIAGNOSTIC DATA: CT of pelvis was performed revealing status post prostatectomy, diffuse metastatic disease to bone, large amount of fecal material in the rectosigmoid, and nodular contour to the posterior wall of the bladder, not significantly changed from prior. Postsurgical CT abdomen revealed approximately a 2.3 cm soft tissue mass just posterior to the left common iliac vein suspicious for metastatic lesion, low attenuation lesion measuring 1.4 cm of parapelvic region of left kidney, most likely representing cyst, atrophy of the right kidney, diffuse metastatic disease to bone and CT appearance of an acute pathologic fracture involving L1 vertebral body. CT of brain was negative for acute hemorrhage or mass effects and small vessel ischemic changes as well as lacunar infarct, right basal ganglia and internal capsule. Negative for acute hemorrhage or mass effect. CT of chest revealed enlarged lymph nodes within the mediastinum with the take-off of the left subclavian artery measuring up to 2.5 cm in size suspicious for metastatic disease. Incidentally noted but not mentioned in the findings of the report. There was 1.7 cm soft tissue lesion within the left subclavicular fossa, multiple nodular infiltrates throughout the right upper lobe and superior segment of the right lower lobe. Differential diagnosis would include infectious etiology versus diffuse osseous metastatic disease. CT of chest was performed to rule out pulmonary embolus as the patient had atypical chest pain during the course of hospitalization. There was no PE or multiple osseous lesions. Stable mediastinal adenopathy and nodular infiltrates persist within the right upper and lower lobes. X-ray of spine revealed diffuse bony sclerotic metastasis, wedge compression deformity of L1, L3-L4, and L4-L5 degenerative disk disease, also facet degenerative disease on the left at L3 to S1.
LABORATORY DATA: CBC day prior to discharge; WBC 5.7, hemoglobin 11.4, hematocrit 35.4, platelets 296, neutrophils 47, bands 12, lymphocytes 35, monocytes 2, eos 4. Sedimentation rate initially was 93, decreased to 37 and increased finally to 60. CRP initially was 8.8, then 5.8, and finally 3.1. Glycosylated hemoglobin was 6.4. Chemistry on the day prior to discharge; sodium 141, potassium 3.9, chloride 102, CO2 of 28, glucose 116, creatinine 0.7, calcium 9.1, total protein 6.4, albumin 2.7, globulin 3.7, alkaline phosphatase 90, ALT slightly elevated at 77 and AST 32. Creatine kinase 16, which is low. Fasting lipids were as follows; cholesterol 103, triglycerides 116, HDL low at 18, LDL 62, VLDL is 23, fasting glucose was 100. Repeat Monospot test was negative. EBV IgG is positive, IgM is negative. Lyme and mycoplasma titers are still pending and EBV titers still pending. Amylase is also slightly elevated at 10.
LABORATORY DATA: Hemoglobin 18, hematocrit 53.4, platelets 78, and white blood cell count 15.2 initially. Repeat hemoglobin was 15.6, hematocrit 47.2, platelets 63, white blood cell count 10.2. PTT was 31.8, PT was 22.1, and INR was 1.92 and elevated. Sodium was 138, potassium 4.2, chloride 104, CO2 of 24, BUN 18, creatinine 1.1, glucose 122, and calcium 8.8. Repeat sodium 132, potassium 2.8, chloride 103, CO2 of 22, BUN 9, creatinine 1.1, glucose 155, calcium 7.8.
EKG showed sinus arrhythmia at 96 to 142 with left axis deviation. Abdominal x-ray showed diffuse bowel gas pattern. Chest x-ray showed some perihilar questionable congestion. He had a CAT scan of the abdomen and pelvis. The CAT scan was consistent with diverticulitis involving the distal descending colon with localized perforation and extraluminal air adjacent to part of the colon consistent with localized perforation of the descending colon. No evidence of intra-abdominal abscess or free fluid. Mild splenomegaly.
