Page of 153 Zoom History and Physical H&P Notes H&P

Page of 153 Zoom History and Physical H&P Notes H&P by Grayck, Eva N. at 12:26 PM Author: Grayck, Eva N. Specialty: Author Type: Physician Filed: 4:45 PM Note Time: 12:26 PM Status: Signed Editor: Grayck, Eva N. (Physician) Related Notes: Original Note by Krebs, Nicholas J. (Resident) filed at 7:13 AM PICU ADMISSION HISTORY & PHYSICAL Date of Service: Chief Complaint: Severe anemia, hematochezia, fatigue History of Present Illness: is a 11 year old previously healthy presenting w/ severe anemia, hematochezia, ascites, and fatigue. Pt in normal state of health until 1 month ago. Started having loose stools around beginning of April. She has been having 4-5 stools per day, normally once per day or every other day. No blood in stool until yesterday, she noticed small volume BRB coating stool and on toilet paper and she had some minor pain w/ this stool. She thinks just one episode of dark/blackish colored stools back about 1 week ago; no tan/acolic stools. No urgency/tenesmus w/ stooling, no pain w/ defecation until yesterday. No abdominal pain until onset yesterday w/ hematochezia. MOC thinks she may have signs of menarche w/ abdominal cramping/bloating, but no vaginal bleeding yet. Pt and family were in on vacation from . During this time family only noticed she was needing to go to bathroom frequently. Family members do not have diarrhea. During trip they were “joking” w/ that she was gaining weight and that her belly was bigger, but thought nothing of it since they weren’t eating the best. Saw PCP on return to started on Flagyl. Only x1 NBNB emesis about 1 week prior to admission w/ start of Flagyl. FOC first noticed her looking pale yesterday; no jaundice or scleral icterus. Pt admits to feeling progressively more dizzy/fatigued, especially over last 1-2 weeks and really felt it yesterday – had dyspnea out of proportion to usual and had difficulties walking up stairs. FOC thinks that she has lost weight. She describes LE weakness. + HA starting during this time w/o vision/hearing changes, ataxia, numbness, tingling. No difficulties w/ concentration. Pt woke this AM w/ severe weakness/fatigue and fell out of bed and was noted to have blood nose. Given this, pt taken to Medical Center. ++ family hx of autoimmune disease: – in PGM, multiple paternal family members w/ polyps; no history of SLE, DM1, autoimmune hepatitis. No known bleeding/clotting disorders. No known hx of sickle cell disease or trait carriers. Medical Center Course: VS: 89/60, HR 119, RR 18, Temp 97.6, SpO2 100%, Wt 28.1 kg (5th %ile), BMI 14.4 Exam: + pale skin, no dyspnea, + abdominal distension w/ diffuse abdominal pain, cap refill < 2 sec - Labs notable for Hgb of 2.8, Hct 9.6; pt continued to be tachycardic - CMP: 137/3.4/108/19/6/0.6<98, Ca-7.4, TP-7.4, total bili-0.6, AST/ALT-26/14, Alk Phos-147, lipase-171, Mg- 2.1 - CBC: 7.6>2.6/9.2<154, MCV-56.2 - Coags: INR of 1.6 - Blood Cx sent x2 pending - NS 500 cc - Transfusions: x2 units PRBCs (35 cc/kg) - O2 started at 1L and increased to 3L via NC - Imaging: CXR - "lungs well expanded, clear, no consolidation or effusion, cardiac silhouette normal, no pneumothorax" XR L humerus - no Fx CT Abd/Pelvis - "cirrhosis, splenomegaly, portal HTN, and large volume ascites, mild cardiomegaly" CT Head - normal, no acute bleed/hemorrhage ( Printed by [113902] at 8/14/14 11:26 AM Page 1 History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) Review of Systems: Constitutional: Positive for fatigue, malaise; Negative for fevers, sweats HEENT: Negative for URI sxs Eyes: Negative for scleral icterus Respiratory: Negative for dyspnea, cough Cardiovascular: Negative for cyanosis, h/o murmur, Gastrointestinal: See history of present illness. Genitourinary: Negative for dysuria Reproductive/Endocrine: Positive for perhaps starting menarche Musculoskeletal: Negative for joint/muscle pain/redness/swelling Hematology/Lymphatic: Negative for easy bleeding/bruising in past Immune/Allergy/Rheumatologic: Negative for allergies, rheumatologic diseases in family Skin: Negative for rash, jaundice Central Nervous: See history of present illness. Birth/Medical/Surgical/Family History: I have reviewed, verified and personally updated the past medical, surgical, family and social history. Diet History: Age appropriate / normal for age, but decreased appetite over last month. Medications No prescriptions prior to admission Drug/Food Allergies: no known allergies Immunizations: stated as up to date, no records available Developmental History: Milestones were all met as expected. Social History: Lives with: parents and one sister Travel: Yes to from Tobacco exposure: No Smoking/alcohol/drug use: No Physical Exam and Current Status: Vital Signs: BP 110/72 | Pulse 89 | Temp 37.5 | Resp 17 | Wt 22.5 kg | SpO2 100% Cuff BP: Systolic (24hrs), Avg:105 mmHg, Min:100 mmHg, Max:110 mmHg Diastolic (24hrs), Avg:69 mmHg, Min:65 mmHg, Max:72 mmHg BP Mean Avg: 77.3 Min: 74 Max: 80 Weight: Height: No data found for this vital: Ht OFC: BMI: There is no height on file to calculate BMI. ( Printed by [113902] at 8/14/14 11:26 AM Page 2 History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) Resp/Oxygen: O2 Flow Rate - LPM: 3 LITERS/MIN General: awake, alert and tired appearing and pale HEENT: Normocephalic and atraumatic, extraocular movements intact, OP clear with moist mucous membranes; + pale mucus membranes Chest: breathing spontaneously and breath sounds are clear to auscultation bilaterally without rales, rhonchi, or wheezes Cardiac: regular rate and rhythm, normal S1 and S2, no murmur, rub, or gallop, central femoral pulses 2+ and symmetric, non-bounding; distal extremity pulses 1+ but equal Abdomen: bowel sounds hyperactive, soft, tenderness to palpation: all quadrants and more so in LLQ and RUQ (minimal in RLQ), distended, voluntary guarding in left lower quadrant , liver edge 2 cm below costal margin, spleen tip 1-2 cm below costal margin, ascites is present, CVA tenderness present bilaterally Extremities: warm, well-perfused without cyanosis, clubbing or edema Neuro: alert and oriented, Cranial nerves: 2-12 intact, reflexes 2+ and symmetric. Sensation grossly normal., strength 5/5 all extremities Skin: pale, especially in cheeks, otherwise no rash Foreign Bodies: PIV x2 Fluids/Nutrition: NPO, no fluids currently Data/Diagnostics Studies: I have reviewed patient's outside medical records. Summary findings are per HPI above. CBC w/diff: Recent Labs Basename 1130 WBC 8.3 RBC 3.43* HGB 8.3* HCT 26.3* MCV 76.8* MCH 24.3* MCHC 31.7* RDW 30.6* PLTCT 124* MPV 9.1 SEGS 71.7* BANDS -- LYMPHS 18.0* MONOS 9.2 EOS 0.4 BASOS 0.7 PLTEST DECREASED 50-130,000 ESR/CRP: Recent Labs Basename 1130 SEDRATE 51* CRP LESS THAN 0.5 CRPHS -- ( Printed by [113902] at 8/14/14 11:26 AM Page 3 History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) Component 11:30 AM 11:30 AM 11:30 AM Patient Temp for Gases 37.0 Lactate Whole Blood 1.34 Lactate WB Conversion 12 User ID 126447 Reticulocyte Count 2.30 Absolute Retic Count 0.079 IRF 0.45 (H) LDH,Total (Serum) 416 CMP Recent Labs Basename 1130 NA 137 K 3.9 CL 109 BIC 18* BUN 5* CRE 0.43 GLU 85 CA 7.6* CAI -- MG -- PHOS -- TP 7.0 ALB 2.5* AGRATIO 0.6 BILT 1.7* DBIL 0.0 IBILI -- ALK 140 AST 31 ALT 23 TRIG -- LFTs Recent Labs Basename 1130 TP 7.0 ALB 2.5* BILT 1.7* ALK 140 AST 31 ALT 23 ( Printed by [113902] at 8/14/14 11:26 AM Page 4 History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) GGT 35* Ammonia, plasma - < 9 COAGS: Recent Labs Basename 1130 PT 19.4* INR 1.63 PTT 45* FIB -- FSP -- HEPARINUNF -- Liver-specific labs: Hepatitis panel - negative Ceruloplasmin, serum - pending EMV Ab profile - pending CMV Ab (IgG/IgM) - pending Ferritin - pending Coagulopathy studies (vitamin-K dependent factors): Factor V - pending Factor VII assay - pending Factor VIII assay - pending Direct Coombs - negative Rheumatologic labs: ANA panel - pending Alpha-1 antitrypsin, serum - pending Smooth muscle Ab - pending Liver/kidney microsomal T1 Ab - pending Celiac studies: Endomysial Ab, serum (IgA) - pending TTG IgA (tissue transglutaminase) - pending Serum IgA - pending Stool studies: Bacterial pathogen group - pending Wet mount - pending Fecal calprotectin - pending C difficile toxin - pending Viral EM - pending Giardia/Crypto - pending Ova/parasites - pending Imaging: ( Printed by [113902] at 8/14/14 11:26 AM Page 5History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) GGT 35* Ammonia, plasma - < 9 COAGS: Recent Labs Basename 1130 PT 19.4* INR 1.63 PTT 45* FIB -- FSP -- HEPARINUNF -- Liver-specific labs: Hepatitis panel - negative Ceruloplasmin, serum - pending EMV Ab profile - pending CMV Ab (IgG/IgM) - pending Ferritin - pending Coagulopathy studies (vitamin-K dependent factors): Factor V - pending Factor VII assay - pending Factor VIII assay - pending Direct Coombs - negative Rheumatologic labs: ANA panel - pending Alpha-1 antitrypsin, serum - pending Smooth muscle Ab - pending Liver/kidney microsomal T1 Ab - pending Celiac studies: Endomysial Ab, serum (IgA) - pending TTG IgA (tissue transglutaminase) - pending Serum IgA - pending Stool studies: Bacterial pathogen group - pending Wet mount - pending Fecal calprotectin - pending C difficile toxin - pending Viral EM - pending Giardia/Crypto - pending Ova/parasites - pending Imaging: ( Printed by [113902] at 8/14/14 11:26 AM Page 5 History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) CT abdomen/pelvis (overread from OSH): Diffuse mesenteric edema and ascites. Splenomegaly. Perhaps slightly lobular contour of the liver without findings of definite cirrhosis. The etiology of the above findings is indeterminate on this examination. By clinical report, the patient has hemoglobin of 2 and likely has low albumin also. CT findings could relate to the low intravascular osmotic pressures and/or extra medullary hematopoiesis. Infectious or toxic insult is also a consideration. U/S abdomen ( ): Hepatosplenomegaly with marked heterogeneous echotexture of the liver. Normal liver Doppler evaluation. Moderate ascites. CXR Normal low lung volume chest radiograph. No mention of cardiomegaly. Impression/Problems: is a 11 year old previously healthy critically ill patient presenting w/ severe anemia (initial Hgb of 2.6 at OSH), hematochezia, mild hepatosplenomegaly, ascites, and fatigue w/ concern initially for extensive liver disease given OSH CT abdomen read of cirrhosis and portal hypertension w/ over-read only showing diffuse mesenteric edema and mild-moderate ascites. Additionally, given normal transaminases, fairly normal GGT, normal bilirubin cirrhosis/end-stage liver disease is not as likely. U/S doppler interrogation shows normal hepatic blood flow and no signs of portal HTN. She has normal mental status and normal ammonia levels, also making significant liver disease not likely, although she does have mild bump in her PT/INR and low albumin (< 2.5), which could be 2/2 protein-wasting enteric-enteropathy and/or mild hepatic synthetic dysfunction. Autoimmune hepatitis given these factor is not likely, at least presentation w/ significant disease. Acute hepatitis is not likely given negative hepatitis panel. Given her fairly normal vital signs on arrival w/ hemoglobin as low as it was this has likely been a chronic compensated problem w/ an acute exacerbation likely 2/2 hematochezia just prior to arrival. Rheumatologic disorders including Crohn's disease is high on differential given elevated ESR (normal CRP), possible bowel wall edema on CT, diffuse/cramping abdominal pain. Ulcerative colitis although certainly possible is less likely given no hx of recurrent hematochezia, tenesmus, LLQ abdominal pain. GI to take patient for upper/lower endoscopy tomorrow. Celiac disease is also quite possible and studies pending. Symptoms could also represent infectious etiology w/ studies pending including bacterial, viral, and parasites. Patient only on Flagyl (treatment for C diff) and no other recent antibiotics. Patient received almost 35 cc/kg in blood products and NS at OSH, but shows no evidence of cardiac or renal failure. She does have elevated reticulocyte count, but not as compensated as one would expect given the degree of anemia. Patient Active Hospital Problem List: Patient Active Problem List Diagnosis •Anemia •Hematochezia •Ascites •Fatigue Plan: RESP: - On continuous SpO2 monitoring - Continue on NC prn for clinical dyspnea, low SpO2 CV: - HDS currently, on continuous CR monitor, looking for acute onset tachycardia, BP drops, signs of an acute bleed - No need for additional fluid resuscitation at this time ( Printed by [113902] at 8/14/14 11:26 AM Page 6 History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) FEN/GI/RENAL: - Clear diet, on Miralax q2hr for bowel cleanout - NPO at 9AM for upper/lower endoscopy - F/u Celiac studies - F/u fecal calprotectin for IBD w/u RHEUM: - F/u ANA panel, smooth muscle Ab, alpha-1 antitrypsin, liver/kidney microsomal T1 Abs HEME: - Repeat H/H tonight, then CBC/Coags in AM - No blood products currently indicated - F/u Factor V, VII, VIII - Getting vitamin K tonight ID: - Monitor fever curve, currently no indication for antibiotics - F/u stool studies - bacterial Cx, wet mount, viral EM, O/P, G/C - Pt w/ yeast in stool, starting PO fluconazole 6 mg/kg qD NEURO: - Monitoring changes in mental status, not expecting this to occur - Tylenol PRN for abdominal pain at this point, could consider morphine if pain severity increases DISPO: To RNF if H/H stable and pt does well in Endoscopy tomorrow Father has been updated with patient's current medical status and management plan. PCP: Paul M. Bogan, M.D. Communication: Patient seen and discussed with PICU team. Nicholas J. Krebs, MD Pediatrics Resident, PL-2 Hospital Pager: PICU ATTENDING NOTE Date of Service: I have examined this critically ill patient, reviewed the bedside flowsheet and lab and radiology results. I have devised and discussed the patient's care plan with the PICU team as noted in the PICU resident admit note. I agree with the findings and plans as noted in the cosigned note attached. Pt is criticallly ill due to following medical diagnosis: severe anemia (Hgb 2.6), ascites, diarrhea and unknown diagnosis with severe malnutrition Management plan requiring ICU level care includes: transfuse/monitor post transfusion at outside facility, ( Printed by [113902] at 8/14/14 11:26 AM Page 7 History and Physical H&P Notes (continued) H&P by Grayck, Eva N. at 12:26 PM (continued) liver/GI consult, eval of underlying disease, NPO, ICU monitoring Cumulative critical care time: 60 minutes Electronically signed by Krebs, Nicholas J. at 5:18 AM Electronically signed by Krebs, Nicholas J. at 7:12 AM Electronically signed by Krebs, Nicholas J. at 7:13 AM Electronically signed by Grayck, Eva N. at 4:45 PM Discharge Summary/Note Discharge Summaries by Neigut, Deborah A. at 12:20 PM Author: Neigut, Deborah A. Specialty: Author Type: Physician Filed: 11:23 AM Note Time: 12:20 PM Status: Signed Editor: Neigut, Deborah A. (Physician) Related Notes: Original Note by Schmidt, Sarah K. (Resident) filed at 12:59 PM Medical Discharge Summary Patient Name: Admit: Discharge: Attending: Neigut, Deborah A. (contact through PCP: Paul M. Bogan, M.D. Diagnoses: Principal/Final Diagnosis: inflammatory bowel disease most consistent with Crohn's Disease Secondary Diagnoses: Anemia, coagulopathy, hepatosplenomegaly, thrombocytopenia Next Steps for PCP: Pending Studies (Results not Final) (Last 100 days) ( Printed by [113902] at 8/14/14 11:26 AM Page 8 Discharge Summary Discharge Summary/Note (continued) Discharge Summaries by Neigut, Deborah A. at 12:20 PM (continued) 0710 TPMT ENZYME ACTIVITY PHENOTYPE 1750 CALPROTECTIN, FECAL 1130 ANTI-NUCLEAR ANTIBODIES Narrative: THE REQUESTED TEST, SERVICE OR PROCEDURE FOR: (cont.) Significant Findings Requiring Outpatient Followup: 1. Coagulopathy- Patient with elevated PT, PTT, low platelets thought to be secondary to inflammatory response. Goal Hgb greater than 7, goal platelets greater than 30,000 especially if evidence of active bleeding ; if PT > 20 Or PTT > 45 would give FFP 2. New diagnosis Crohn’s – Patient discharged home on po prednisone. This will need to be tapered with GI clinic as an outpatient. She was also started on Pentasa ( 5- ASA) with a gradual increase in dosage to goal of 750 mg tid per Dr. Neigut’s recommendation. Family is accepting of new diagnosis but still have significant concerns for and social work support will be greatly appreciated. 3. Nutational risk with Crohn’s – Patient discharged home on MVI, Zinc, low fiber low residue diet with continued boost supplementation. Nutrition had additionally recommended starting Ca (1000 mg) and Vit D (1000 IU) supplements and fish oil (2-4 g/day) these additional supplements were not started prior to discharge to help avoid overwhelming family with new medications right at d/c. They would be discussed at follow-up this week with GI nutrition. Discharge Medications and Treatments: Medications To Be Taken At Home (After Discharge) As of 12:20 PM ( Printed by [113902] at 8/14/14 11:26 AM Page 9 Patient’s Home Medications after Discharge Dose Refill Commonly known as: PREVACID 15 mg (1 cap) by mouth every day 1 tab by mouth every day Dose: 15 mg Refills: 1 Dose: 1 tab mesalamine 500 MG Cr capsule 500 mg (1 cap) by mouth every 8 hours When starting medication please take one dose ( morning dose) only for three days, next Take two doses ( morning, afternoon) for three days and then start taking as instructed three times a day. Please call GI clinic with any questions about dosing. Dose: 500 mg Refills: 0 Refills: 2centrum kids with iron 60 MG Chew tablet lansoprazole 15 MG Dr capsuleDischarge Summary Discharge Summary/Note (continued) Discharge Summaries by Neigut, Deborah A. at 12:20 PM (continued) 0710 TPMT ENZYME ACTIVITY PHENOTYPE 1750 CALPROTECTIN, FECAL 1130 ANTI-NUCLEAR ANTIBODIES Narrative: THE REQUESTED TEST, SERVICE OR PROCEDURE FOR: (cont.) Significant Findings Requiring Outpatient Followup: 1. Coagulopathy- Patient with elevated PT, PTT, low platelets thought to be secondary to inflammatory response. Goal Hgb greater than 7, goal platelets greater than 30,000 especially if evidence of active bleeding ; if PT > 20 Or PTT > 45 would give FFP 2. New diagnosis Crohn’s – Patient discharged home on po prednisone. This will need to be tapered with GI clinic as an outpatient. She was also started on Pentasa ( 5- ASA) with a gradual increase in dosage to goal of 750 mg tid per Dr. Neigut’s recommendation. Family is accepting of new diagnosis but still have significant concerns for and social work support will be greatly appreciated. 3. Nutational risk with Crohn’s – Patient discharged home on MVI, Zinc, low fiber low residue diet with continued boost supplementation. Nutrition had additionally recommended starting Ca (1000 mg) and Vit D (1000 IU) supplements and fish oil (2-4 g/day) these additional supplements were not started prior to discharge to help avoid overwhelming family with new medications right at d/c. They would be discussed at follow-up this week with GI nutrition. Discharge Medications and Treatments: Medications To Be Taken At Home (After Discharge) As of 12:20 PM ( Printed by [113902] at 8/14/14 11:26 AM Page 9 Patient’s Home Medications after Discharge Dose Refill Commonly known as: PREVACID 15 mg (1 cap) by mouth every day 1 tab by mouth every day Dose: 15 mg Refills: 1 Dose: 1 tab mesalamine 500 MG Cr capsule 500 mg (1 cap) by mouth every 8 hours When starting medication please take one dose ( morning dose) only for three days, next Take two doses ( morning, afternoon) for three days and then start taking as instructed three times a day. Please call GI clinic with any questions about dosing. Dose: 500 mg Refills: 0 Refills: 2centrum kids with iron 60 MG Chew tablet lansoprazole 15 MG Dr capsule Discharge Summary Discharge Summary/Note (continued) Discharge Summaries by Neigut, Deborah A. at 12:20 PM (continued) Follow Up/Information Provided to Family: Discharge Follow-up Appointment Our schedulers will contact you with a follow-up with Dr. Neigut this week. If you have any questions or concerns please call clinic at Follow-up appointment(s) GI clinic Discharge Activity Discharge activity AS TOLERATED Discharge Instructions It was a pleasure caring for Please do not hesitate to contact GI clinic with any questions before your next appointment. At that appointment more specifics about management will be discussed. Until them please continue giving her prednisone daily ( they will talk with you about how to wean this off at the appointment.) You can decide to send her to school on Monday if she is feeling better. If she does not feel up to it you can keep her home until you think she is ready. Please return to the hospital/ call GI clinic immediately if is vomiting so much she can not tolerate food/water, she has a fever greater than 100.3 F, she starts bleeding ( nose bleeds, vomiting blood, passing large amount of blood in stool) or if she looks or acts sicker. Discharge Diet Please continue the low fiber, low residue diet as discussed in the hospital. Please remember to keep a food diary of foods that seem likke the trigger worsening pain. If you can continue drinking the boost ( 2 bottles) a day. You will get a chance to talk to the nutritionist at your appointment in GI clinic if there are further questions. Discharge diet As Specified Brief Reason for Hospitalization: is a 11 year old admitted on for severe anemia, hematochezia, ascites. Per Dr. ( Printed by [113902] at 8/14/14 11:26 AM Page 10 Commonly known as: DELTASONE 40 mg (2 tabs) by mouth every morning 250 mg (1 cap) by mouth every 8 hours When starting medication please take one dose (morning dose) only for three days, next take two doses (morning,afternoon) for three days and then start taking as instructed three times a day. Please call GI clinic with any questions about dosing. Dose: 40 mg Refills: 0 Dose: 250 mg zinc sulfate 220 MG Caps Commonly known as: ORAZINC 220 mg (1 cap) by mouth every 24 hours Dose: 220 mg Refills: 1 Refills: 0mesalamine 250 MG Cr capsule predniSONE 20 MG Tabs Discharge Summary Discharge Summary/Note (continued) Discharge Summaries by Neigut, Deborah A. at 12:20 PM (continued) Neiderstat, ” Pt in normal state of health until 1 month ago when she had loose stools, hematochezia, fatigue with ultimate collapse with no LOC leading to evaluation at Medical Center Course. At OSH, + pale skin, no dyspnea, + abdominal distension w/ diffuse abdominal pain, cap refill < 2 sec. Labs notable for Hgb of 2.8, Hct 9.6; tachycardic, INR of 1.6. Given NS 500 cc, 2 units PRBCs (35 cc/kg), O2 3L via NC. CT Abd/Pelvis - "cirrhosis, splenomegaly, portal HTN, and large volume ascites, mild cardiomegaly" (overread here- see bottom of note). CT Head - normal, no acute bleed/hemorrhage. Transferred to CHC. CHC PICU Course: Resp: in PICU, weaned from 3L to RA with PRBC replacement. Prior to transfer to Liver team, pt with increased WOB, ?wheeze, placed on 3L. Nursing, parents, PICU felt this was anxiety, albuterol never administered prior to resolution of symptoms. Transitioned quickly to RA. CXR obtained with sl fluid in minor fissure. CV: tachycardic at first in 120s, now resolved with fluid resuscitation. GI: upon admission to CHC with Hb of 8.3/26.3. Transfused 6.5 ml/kg PRBCs, 2 units FFP. Initally started on fluconazole for yeast in stool by PICU, discontinued by GI team for normal physiologic finding. No antibiotics. CT from OSH overread as only fluid in abdomen (no contrast, thus could not see bowel wall thickening), NO cirrhosis. Taken to upper/lower endoscopy by GI with findings consistent with Crohn's. Started on methylpred BID, low residue/low fiber/low lactose diet. One stool overnight with sl blood, not concerning for acute bleed given some bleeding on scope yesterday per GI. Nutrition started Boost supplement, zinc supplements, multivitamins. HEME: Transfused as above, stable H/H prior to transfer to the floor without active bleeding. Hematology consulted for recommendations of anticoagulation with IBD. Would not anticoagulate until flare of IBD is controlled (noted from Heme pending). NEURO: required tylenol for pain until after eating large meal with ab pain, then oxycodone x1. Heat pack prn for belly pain. SOCIAL: parents at bedside throughout admission." Please refer to H+P note for complete details of presenting illness. Brief Hospital Course (summary of care, services provided and significant findings): Active Hospital Problem List: Inflammatory bowel disease most consistent with Crohn's disease: was initially admitted to ICU for severity of anemia associated with GI losses. Please see brief PICU statement above for specifics. Patient was started on IV methylpred and underwent endoscopy with biopsies most consistent with Crohn's. Biopsy showed severe diffuse chronic active colitis with poorly formed granulomas in the colon- ascending, transversae, descending, cecum and Rectosigmoid. ascites, splenomegaly and anemia were all felt to be secondary to ongoing GI losses with significant degree of inflammatory response. underwent UGI with Small bowel follow-through that was normal. On was transitioned to oral steroids with improved appetite, stools and overall demeanor. She will continue on steroids as an outpatient. Taper needs to be determined. She will also start 5-ASA as an outpatient with upward titration in dosing. Social work met wit family prior to discharge to help support family and patient with new diagnosis and overed some supportive services. Family continues to hope for Furth social work involvement as an outpatient. Malnutrition Hospital Course: was started on a low fiber, low residue diet. Supplements initiated included zinc, MVI. Nutrition was consulted and had further recommendations for vitamin support - please see above. Additionally trialed Boost and seemed to like it. Further discussions on nutritional therapy will need to be held at subsequent GI clinic visits. was advised to continue a low lactose diet and to keep a food diary to help ( Printed by [113902] at 8/14/14 11:26 AM Page 11Discharge Summary Discharge Summary/Note (continued) Discharge Summaries by Neigut, Deborah A. at 12:20 PM (continued) Neiderstat, " Pt in normal state of health until 1 month ago when she had loose stools, hematochezia, fatigue with ultimate collapse with no LOC leading to evaluation at Medical Center Course. At OSH, + pale skin, no dyspnea, + abdominal distension w/ diffuse abdominal pain, cap refill < 2 sec. Labs notable for Hgb of 2.8, Hct 9.6; tachycardic, INR of 1.6. Given NS 500 cc, 2 units PRBCs (35 cc/kg), O2 3L via NC. CT Abd/Pelvis - "cirrhosis, splenomegaly, portal HTN, and large volume ascites, mild cardiomegaly" (overread here- see bottom of note). CT Head - normal, no acute bleed/hemorrhage. Transferred to CHC. CHC PICU Course: Resp: in PICU, weaned from 3L to RA with PRBC replacement. Prior to transfer to Liver team, pt with increased WOB, ?wheeze, placed on 3L. Nursing, parents, PICU felt this was anxiety, albuterol never administered prior to resolution of symptoms. Transitioned quickly to RA. CXR obtained with sl fluid in minor fissure. CV: tachycardic at first in 120s, now resolved with fluid resuscitation. GI: upon admission to CHC with Hb of 8.3/26.3. Transfused 6.5 ml/kg PRBCs, 2 units FFP. Initally started on fluconazole for yeast in stool by PICU, discontinued by GI team for normal physiologic finding. No antibiotics. CT from OSH overread as only fluid in abdomen (no contrast, thus could not see bowel wall thickening), NO cirrhosis. Taken to upper/lower endoscopy by GI with findings consistent with Crohn's. Started on methylpred BID, low residue/low fiber/low lactose diet. One stool overnight with sl blood, not concerning for acute bleed given some bleeding on scope yesterday per GI. Nutrition started Boost supplement, zinc supplements, multivitamins. HEME: Transfused as above, stable H/H prior to transfer to the floor without active bleeding. Hematology consulted for recommendations of anticoagulation with IBD. Would not anticoagulate until flare of IBD is controlled (noted from Heme pending). NEURO: required tylenol for pain until after eating large meal with ab pain, then oxycodone x1. Heat pack prn for belly pain. SOCIAL: parents at bedside throughout admission." Please refer to H+P note for complete details of presenting illness. Brief Hospital Course (summary of care, services provided and significant findings): Active Hospital Problem List: Inflammatory bowel disease most consistent with Crohn's disease: was initially admitted to ICU for severity of anemia associated with GI losses. Please see brief PICU statement above for specifics. Patient was started on IV methylpred and underwent endoscopy with biopsies most consistent with Crohn's. Biopsy showed severe diffuse chronic active colitis with poorly formed granulomas in the colon- ascending, transversae, descending, cecum and Rectosigmoid. ascites, splenomegaly and anemia were all felt to be secondary to ongoing GI losses with significant degree of inflammatory response. underwent UGI with Small bowel follow-through that was normal. On was transitioned to oral steroids with improved appetite, stools and overall demeanor. She will continue on steroids as an outpatient. Taper needs to be determined. She will also start 5-ASA as an outpatient with upward titration in dosing. Social work met wit family prior to discharge to help support family and patient with new diagnosis and overed some supportive services. Family continues to hope for Furth social work involvement as an outpatient. Malnutrition Hospital Course: was started on a low fiber, low residue diet. Supplements initiated included zinc, MVI. Nutrition was consulted and had further recommendations for vitamin support - please see above. Additionally trialed Boost and seemed to like it. Further discussions on nutritional therapy will need to be held at subsequent GI clinic visits. was advised to continue a low lactose diet and to keep a food diary to help ( Printed by [113902] at 8/14/14 11:26 AM Page 11 Discharge Summary Discharge Summary/Note (continued) Discharge Summaries by Neigut, Deborah A. at 12:20 PM (continued) identify trigger foods. She was tolerating a full diet prior to discharge. Coagulopathy: required PRBC, FFP for abnormality of labs. Hematology was consulted and Felt like coagulopathy was related to IBD- SIRS leading to activation of cytokine network and activation of coagulation with consumption of clotting factors. Additionally loss of clotting proteins in diarrhea likely contributed to overall state. had a mixed picture supporting hematologies assumption with with low factor V ( not vit K dependent), low factor VII ( vit K dependent) and factor VIII ( made by hepatocytes, hepatic sinusoidal endothelial cells and also Acute phase reactant). No VTE prophylaxis was initiated as treatment of underlying IBD should normalize coagulopathy. was encouraged to sit up and reduce immobility, transfusion thresholds as mentioned above. One dose of IV vitamin K was given prior to discharge. Operative Procedures: endoscopy with biopsys Significant Findings: new diagnosis IBD most consistent with Crohn's Allergies: has no known allergies. 24 hr Events/Discharge Exam: Events in last 24 hours: Tolerating po steroids well. Feeling better, eating breakfast. IV Vitamin K x 1 Exam: BP 94/58 | Pulse 109 | Temp 37.3 | Resp 24 | Ht 140 cm | Wt 22.5 kg | SpO2 100% Oxygen:RA Gen: Alert, smiling, sitting up HEENT: , pale conjunctiva, MMM Neck: there is full active range of motion Chest: Easy WOB, breath sounds clear Cardiovascular: RRR, good peripheral perfusion Abdomen: Distended, spleen palpable 3 cm BCM at umbilicus, liver palpable 4 cm BCM mildly tender to palpation RUQ Extremities: warm, well-perfused without cyanosis, clubbing or edema Skin: pink, warm, well perfused, no rashes Neurological: grossly nonfocal, cranial nerves 2-12 intact General Discharge Information: Condition on Discharge: Good Discharge Disposition: Discharged to: Home Sarah K Schmidt, M.D. Pediatrics PL-3 Attending Note Date of Service: I saw and evaluated the patient. I discussed the case with the Resident, Dr. Schmidt

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