Pt. Name: Getzinger, Kristen E Admitted: 06/06/2013 Discharged: 06/20/2013 Date of Birth: 05/20/1976 Physician: Samih Bittar, M.D. DISCHARGE SUMMARY Principal Diagnoses:1. Fanconi syndrome with multiple electrolyte imbalances.2. Severe ileus.3. Non-anion gap metabolic acidosis. Secondary Diagnoses:1. Hepatitis C infection.2. History of epidural abscess, status post surgery.3. History of bipolar disorder. Hospital Course:1. Fanconi syndrome. The patient presented to the patient with generalized weakness. The patient was brought to the hospital on the wheelchair. Her potassium on admission was 1.5 and her bicarbonate was 10, pH was 7.05, and magnesium and phosphorus were low as well. All electrolytes were replaced aggressively, and Nephrology were consulted since her creatinine on admission was high and she was _____ all these electrolytes, and she was she was very acidotic on admission. She was started on bicarbonate drip running at 200 mL/h at the time of admission, and Nephrology agreed on the same management and they did further workup, which confirmed that the patient has a Fanconi syndrome secondary to tenofovir and upon reviewing her past basic metabolic profiles, her potassium was most of the time in the lower side, which suggests that this problem was chronic. The patient kept losing a potassium and it was difficult to stop the IV bicarbonate as she was getting acidotic every time we stopped the IV bicarbonate. She was getting oral bicarbonate along with IV. The patient was getting 80 of potassium once daily for the first 8 days. She was getting IV bicarbonate and maxed on oral bicarbonate. In the last 3 days of admission, electrolytes were all corrected and within normal limits, and her pH and bicarbonate were corrected. IV bicarbonate was discontinued 2 days prior to discharge and she was doing fine. Her bicarbonate on discharge was 24 with only oral bicarbonate. So for now, we will continue potassium supplements 20 b.i.d. of potassium of KCl and will continue replacing her magnesium and phosphorus orally. She will also get oral bicarbonate, she will get weekly BMP for the first month, and she will follow up with Nephrology for further management of her electrolyte imbalance.2. Severe ileus. The patient developed abdominal distention and ileus 2 days after admission and this could be related to hypokalemia along with narcotics that she was getting for her chronic back pain after the surgery that she had for epidural abscess. All the pain medications were stopped, and GI was consulted for management of this severe ileus. GI agreed on NG tube suctioning, which NG tube aspiration was positive for blood and there was 300 mL of coffee-ground emesis aspirated through the NG tube. Her hemoglobin dropped from 9.8 to 7.5, so she was transfused 2 units; and then during her admissions, since then her hemoglobin was stable. She did not vomit any blood and she did not notice any blood in her stool as well. GI recommended to do EGD as an outpatient, as she was vitally stable and she was not actively bleeding. We will be getting serial abdominal x-rays based on Surgery's recommendations, and 3 days after putting the NG tube, we removed it and the patient was able to tolerate the clears at the first day and then a regular diet without problems. The patient had constipation, who was only having diarrhea; and 2 days prior to discharge we started her on enema, which helped her a lot along with MiraLAX. The patient passed a regular stool the day before discharge, and the x-ray showed resolution of her ileus. Last x-ray prior to discharge showed resolution of her ileus.3. Two days after admission, the patient developed shortness of breath. Her chest x-ray showed pulmonary congestion versus interstitial lung disease. So V/Q scan was done, which showed no evidence of pulmonary embolism and she was transferred on the third day of admission to ICU for close monitoring. During her stay in the ICU, she was bronched and her bronchoscopy result was unremarkable, and bronchioalveolar lavage was sent for culture and it did not show any growth or any bacteria including pneumocystic carinii infection. The infiltrates in her lungs and the condition of her lungs resolved in 2 days, and she was breathing on room air without having any difficulty breathing for the rest of her hospital stay.4. Iron-deficiency anemia. On admission, hemoglobin was 9.7 and we did an iron study, which was positive for iron-deficiency anemia. The patient was started on IV iron but given her persistent ileus, iron supplement was stopped temporarily, as we will reassess the need for iron supplement after she sees her primary care physician.5. Malnutrition. The patient was having difficulty eating and drinking because of odynophagia and oral mucositis. She was started on Magic Mouth and Diflucan, and she improved drastically after starting with these 2 medications. She was able to eat and drink without problems. Her LFTs shows an albumin of 1.6 during the admission. So on the day of discharge, we encouraged the patient to drink more protein shakes to help her get her strength back.6. Drug abuse. The patient has history of drug abuse heroin, and on admission, she was only positive for opiates and benzodiazepines, which she was taking at home. During the day before discharge, patient's nurse noticed that the patient was hiding small bag under her socks. So, _____ was called and he ordered urine tox, which was positive for marijuana, 50 THC on urine tox. The previous urine tox done on June 7, 2013 was negative for marijuana. Her boyfriend was in the room on that day, so we think the patient was given marijuana during her hospital stay; although, she denies it and we searched all the draws and there was nothing left in the room at that time. Physical Therapy evaluated the patient during admission and they recommended ECF for further rehabilitation. The patient was able to walk with a walker unassisted and she refused to go to ECF despite our recommendations. Followup:1. The patient will be will follow up with Dr. Vetteth in Nephrology Clinic on July 8, 2013 at 2 p.m. She will be given the number to call at 2 p.m.2. The patient will follow up with Dr. Duggan in 1-2 weeks, and she will be given the number to call and make an appointment.3. The patient will follow up with GI Clinic, EGD in 2 weeks, for an upper GI endoscopy to rule out esophagitis.4. The patient will follow up with Dr. Duggan in 1-2 weeks. Discharge Medications:1. The patient will be sent home with Bumex 1 mg tablet once daily, as she was having bilateral lower extremities edema and this is per Nephrology's recommendation.2. She will be sent home with spironolactone 25 mg once daily.3. Clonazepam 0.5 mg oral 3 times per day and this is per Psychiatry's recommendations.4. Diflucan 150 mg once daily.5. Doxycycline 100 mg 2 times per day.6. Folic acid 1 mg once daily.7. Isentress 400 mg tablet 2 times per day.8. Potassium chloride 20 mEq oral 2 times per day.9. Magnesium oxide 400 mg tablet 3 times per day.10. Norvir 100 mg oral daily.11. Ofloxacin 0.3% eye drops 4 times per day.12. Protonix 40 mg 2 times per day.13. Prednisolone acetate 1% eye drops 4 times per day.14. Prezista 800 mg once daily.15. Sodium bicarbonate 1950 mg oral 3 times per day.16. As needed medication, cyclobenzaprine 5 mg tablet 2 times per day as needed for muscle spasm.17. Oxycodone 5 mg oral every 6 hours as needed for breakthrough pain.18. Neutra-Phos 1 packet 3 times per day.