tokens: 433651389 CTMC 81247987 625670 08/16/1998 12:00:00 AM MENTAL STATUS CHANGE , CELLULITIS Signed DIS Admission Date : 08/16/1998 Report Status : Signed Discharge Date : 08/18/1998 PRINCIPAL DIAGNOSIS : MENTAL STATUS CHANGES . OTHER DIAGNOSES : 1) AORTIC STENOSIS . 2) MITRAL REGURGITATION . 3) STATUS POST FALL . 4) HISTORY OF TRANSIENT ISCHEMIC ATTACK / CEREBROVASCULAR ACCIDENT . 5) RIGHT LOWER EXTREMITY WOUND . 6) ATRIAL FIBRILLATION . HISTORY OF PRESENT ILLNESS : The patient is an 88 year-old woman undergoing treatment for a right lower extremity cellulitis who was transferred from Child for worsening cellulitis and new confusion . The patient has a history of severe aortic stenosis and was recently admitted to the Retelk County Medical Center for a Nafcillin sensitive Staphylococcus aureus cellulitis of the right leg treated with a course of Nafcillin and Levofloxacin . There was also a right leg fluid collection that was incised and drained on August 1 , 1998 . The patient was sent to rehabilitation on Levofloxacin orally . Although details were not available at the time of admission , apparently , she had done well until the 24 hours proceeding admission when the cellulitis was felt to be worsening . She had also been noted to be confused and combative during that 24 hour period . As her baseline mental status is completely alert and oriented , this caused concern amongst the staff of the rehabilitation center and the patient was transferred to the Retelk County Medical Center . PAST MEDICAL HISTORY : 1) Aortic stenosis , severe , echocardiogram in July of 1998 with a peak gradient of 6-8 mm of mercury , aortic valve area calculated to be 0.5 cm squared by the continuity equation . The patient has a history of congestive heart failure . Calculated ejection fraction was 45-50% . 2) Mitral regurgitation , 2+ on July of 1998 echocardiogram . 3) History of atrial fibrillation . 4) History of cerebrovascular disease . 5) Hypertension . 6) History of temporal arteritis on chronic steroids . 7) History of colitis . 8) History of vertebral body fractures . MEDICATIONS ON ADMISSION : 1) Digoxin 0.125 mg p.o. q. day . 2) Lasix 80 mg p.o. b.i.d. 3) Aspirin 81 mg p.o. q. day . 4) Coumadin 2 mg p.o. q.h.s. 5) Zaroxolyn 2.5 mg p.o. q. day . 6) Toprol XL 50 mg p.o. q. day . 7) Potassium 20 mEq p.o. q. day . 8) Prednisone 5 mg p.o. q.o.d. 9) Fosamax 10 mg p.o. q. day . 10) Levofloxacin 250 mg p.o. q. day . 11) Axid 150 mg p.o. b.i.d. 12) Buspar 5 mg p.o. t.i.d. 13) Zyrtec 10 mg p.o. q. day . ALLERGIES : The patient had no known drug allergies . SOCIAL HISTORY : The patient is presently staying at the Gangistown Hospital Center . She has a son who is actively involved in her care . PHYSICAL EXAMINATION : Physical examination on admission revealed an elderly woman , sleeping , responsive only to noxious stimuli after having received some sedation in the emergency department . Vital signs : Heart rate 60 , respiratory rate 18 , blood pressure 116/80 , temperature 97.1 degrees , oxygen saturation 93% on room air . Head and neck examination was benign . Skin examination was notable for a leg ulcer and cellulitis to be delineated below . There were no spider angiomata . Neck was supple with no thyromegaly . Lungs were clear to auscultation bilaterally . The heart examination revealed that the patient had a sustained PMI which was located in the left mid clavicular line , S1 , near complete obliteration of the second heart sound by a two out of six high pitched murmur peaking at mid to late systole and heard across the precordium . It radiates to both carotids bilaterally . There was also a blowing holosystolic murmur heard at the patient &apos;s apex to axilla . There was no S3 appreciated . Vascular examination was notable for 1+ carotid impulses which were diminished and delayed and the above mentioned transmitted cardiac murmurs . Abdominal examination revealed that the abdomen was soft , non-tender , non-distended , no organomegaly , no masses , normal active bowel sounds . The patient &apos;s extremity examination was notable for erythema of the right calf with a small ulcer with a relatively clean base . Neurological examination revealed that the patient was quite sedated at this time having received some medications . She was arousable only to painful stimuli . Her pupils were reactive bilaterally . Her face was symmetric . She had an intact gag reflex . She was able to move all four of her extremities in response to pain . Her deep tendon reflexes were slightly diminished at 1+ bilaterally , but symmetric . LABORATORY : The patient &apos;s laboratory data on admission is as follows : Sodium was 142 , potassium 3.3 , chloride 99 , BUN 23 , creatinine 1.1 . AST was 25 , alkaline phosphatase 130 , total bilirubin 3.2 , albumin 3.4 , calcium 8.8 . Digoxin level was 0.8 . Hematocrit was 33.0 , platelet count 627 , white blood cell count 10,000 , MCV 79.8 . Coagulation studies revealed a PT of 17.4 seconds with an INR of 2.1 , PTT 25.5 . The patient &apos;s admission chest x-ray revealed no infiltrate , no congestive heart failure . Head CT scan performed in the emergency department revealed no bleed . Urinalysis revealed trace microscopic hematuria with 47 red blood cells per high powered field , 1+ bacteria . HOSPITAL COURSE : 1) Mental status changes : On admission to the emergency room , the patient was somewhat argumentative and confused as well as uncooperative with procedures . A neurologic work-up was undertaken which included a CT scan of the head which revealed no acute bleed and a lumbar puncture which revealed a glucose of 72 , protein 65 , white blood cell count 19 , red blood cell count 11,500 with no evidence of xanthrochromasia . The Neurology Service evaluated the patient who felt that her agitation was most likely due to infection , her multiple medications , or her metabolic condition . The patient &apos;s mental status slowly began to recover , however on the morning of the first day of admission , August 16 , 1998 , the patient was found after having fallen . A neurological examination was performed which revealed no abnormality and imaging included a head scan which revealed no bleed and a cervical spine series which revealed degenerative joint disease but no obvious fracture . The patient decided not to pursue further testing with a neck CT scan . At the time of discharge , the patient &apos;s mental status is back to its baseline . 2) Right lower extremity cellulitis : The patient was evaluated by the Surgical Service who felt that the wound was clean with some erythema but without evidence of true cellulitis . The patient &apos;s antibiotics were discontinued with the thought that prolonged antibiotics only put her at more risk for infection . 3) Cardiac : The patient has a history of critical aortic stenosis and mitral regurgitation . Fortunately , these issues were not active during the present admission . 4) Status post fall : The patient did fall while inhouse . A head CT scan and cervical spine series were negative . The patient appeared to have no deficits at the time of discharge . 5) Atrial fibrillation : The patient &apos;s Coumadin was continued . 6) Abnormal liver function tests : On admission , the patient was noted to have elevated bilirubins in the 3 range and mildly elevated alkaline phosphatase consistent with a cholestatic picture . These liver function tests will be followed closely as an outpatient . MEDICATIONS ON DISCHARGE : 1) Aspirin 81 mg p.o. q. day . 2) Digoxin 0.125 mg p.o. q. AM . 3) Lasix 40 mg p.o. b.i.d. 4) Zaroxolyn 0.25 mg p.o. q. day . 5) Prednisone 5 mg p.o. q.o.d. 6) Coumadin 2 mg p.o. q.h.s. 7) Kay Ciel 20 mEq p.o. q. day . 8) Fosamax 10 mg p.o. q. day . 9) Amitriptyline 10 mg p.o. q.h.s. 10) Buspar 5 mg p.o. t.i.d. FOLLOW-UP : The patient will be followed at rehabilitation by her primary care physician , Dr. Both . Dictated By : TIA BREUNMULL , M.D. OH29 Attending : RA S. BOTH , M.D. YT79 WH234/2364 Batch : 4025 Index No. FSYAMR79X6 D : 08/18/98 T : 08/18/98