tokens: Admission Date : 2018-12-26 Discharge Date : 2019-01-10 Date of Birth : 1949-02-09 Sex : F Service : MEDICINE Allergies : Losartan / Aspirin / Lisinopril-Hctz Attending : Donald I Patrick , M.D. Chief Complaint : fever Major Surgical or Invasive Procedure : Intubation for airway protection tunneled line change over wire 2019-01-08 History of Present Illness : 69 y/o female wtih PMH significant for ESRD on HD , type 2 DM , and recent PE resulting in PEA arrest admitted through the Juan with sepsis of unknown etiology . Pt was recently admitted to The Hospital for Orthopedics from 12-07 thorugh 12-14 with hypotension thought to be secondary to overdiuresis at HD. However , a septic component to the hypotension was also considered as the pt was found to have citrobacter in her urine and C diff in her stool . Pt was then discharged to Arbour-Fuller Hospital Senior Life where she was in her normal state of health until three days ago . Her son reports that she then developed a headache and fevers started three days ago which were treated with tylenol . Then , this morning she developed fatigue and did not eat well . He son also notes that she appeared to be working hard to breath . She was found to be febrile to 101.9 and received levoflox and vancomycin . Pt was then sent to the The Hospital for Orthopedics Juan for further evaluation . Per notes , pt denied SOB , CP , and abdominal pain prior to intubation . She did complain of a left frontal headache . In the Juan , the pt 's VS were singificant for a fever of 103.8 , tachycardia in the 130s-150s , and initial hypertensive in the 140s . Her oxygen saturation was 96% on RA but she was tachypneic to 31 . She was obtunded and was thus intubated for airway protection . Post-intubation , the pt 's BP acutely dropped to 58/19 in the setting of propofol . When this medication was discontinued , her BP came back up to the 70s-90s / 30s-50s . Pt was then initiated on the sepsis protocol . In the Juan , she received vancomycin , levofloxacin , flagyl , and cefepime ( 2 gm ). She received a total of 4 liters of NS then was started on levophed for continued hypotension . Pt is now transferred to the FICU for further care . Per pt 's son , she is bedbound at baseline due to her multiple LE femur fractures . Past Medical History : 1. Type 2 diabetes mellitus 2. Diabetic nephropathy resulting in ESRD for which she is on HD . Pt was due for HD but missed it secondary to her illness . She normally receives HD on Mon , Wed , and Fri . 3. Status post left femur fracture 4. Hyponatremia 5. Hypercholesterolemia 6. Unsteady gait 7. Cataracts 8. Back pain 9. Hypertension 10. Anemia of chronic disease 11. S/P L shoulder hemiarthroplasty following a left humeral fracuture in 2018-11-10- Dumas was complicated by a PEA arrest secondary to PE . 12. PE 2018-11-17 leading to PEA arrest Social History : Lives with son who is very involved and well informed regarding her care needs . Non smoker . No EtOH Family History : Noncontributory Physical Exam : 94.5 132/50 108 15 100% AC 500 / 15 / .50 / PEEP 5 Gen - Sedated and intubated . Grimaces eyes when they are opened . HEENT - NC AT . Right pupil ERRL . Surgical left pupil . Anicteric sclera . MMM . Cardiac - RRR . S1 S2 . No m,r,g . Pulm - CTA anteriorlly . Abdomen - Obese . Soft . NT . ND . Positive bowel sounds . Extremities - Feet mildly cool . 2+ DP pulses bilaterally . 2+ pitting edema bilateral LE . Skin breakdown between toes . Pressure ulcers under bilateral LE right above the ankles . Do not appear infected . Question mild erythema and warmth of left LE . Neuro - Sedated . Downgoing toes bilaterally . Scruntches eyes closed when try to open them . Pertinent Results : 2018-12-26 11:10 PM LACTATE - 1.8 2018-12-26 10:53 PM CRP - 46.2 * 2018-12-26 10:53 PM SED RATE - 33 * 2018-12-26 09:54 PM TYPE - MIX TEMP - 35.6 RATES -/ 15 TIDAL VOL - 500 PEEP - 5 O2 - 50 PO2 - 34 * PCO2 - 39 PH - 7.32 * TOTAL CO2 - 21 BASE XS - -6 - ASSIST / CON INTUBATED - INTUBATED 2018-12-26 09:54 PM LACTATE - 1.6 2018-12-26 09:44 PM GLUCOSE - 210 * UREA N - 29 * CREAT - 3.2 * SODIUM - 139 POTASSIUM - 3.9 CHLORIDE - 112 * TOTAL CO2 - 17 * ANION GAP - 14 2018-12-26 09:44 PM CALCIUM - 6.2 * PHOSPHATE - 1.7 * MAGNESIUM - 0.9 * 2018-12-26 09:44 PM CORTISOL - 10.3 2018-12-26 09:44 PM WBC - 9.0 RBC - 2.93 * HGB - 9.0 * HCT - 29.7 * MCV - 101 * MCH - 30.8 MCHC - 30.4 * RDW - 24.1 * 2018-12-26 09:44 PM NEUTS - 65.2 LYMPHS - 25.2 MONOS - 6.0 EOS - 3.3 BASOS - 0.4 2018-12-26 09:44 PM HYPOCHROM - 3+ ANISOCYT - 3+ POIKILOCY - 1+ MACROCYT - 3+ MICROCYT - 1+ 2018-12-26 09:44 PM PLT COUNT - 177 2018-12-26 08:28 PM CORTISOL - 9.3 2018-12-26 08:28 PM URINE COLOR - Yellow APPEAR - SlHazy SP Barajas - 1.005 2018-12-26 08:28 PM URINE BLOOD - LGE NITRITE - NEG PROTEIN - 500 GLUCOSE - TR KETONE - NEG BILIRUBIN - NEG UROBILNGN - NEG PH - 7.0 LEUK - NEG 2018-12-26 08:28 PM URINE RBC - 225 * WBC - 8 * BACTERIA - NONE YEAST - NONE EPI - < 1 2018-12-26 02:40 PM CK ( CPK )- 350 * 2018-12-26 02:40 PM CK - MB - 3 cTropnT - 0.40 * MICRO : sputum 12-27 : grm stn and cx negative infl A and B 12-27 : negative CSF grm stn / cx : negative urine cx 12-26 : > 100K VRE likely colonized , 01-03 yest and VRE c diff neg : 12-28 , 12-31 , 01-01 , 01-02 . bld cx 12-26 , 12-27 , 12-28 , 12-31 - NG . 01-01 , 01-02 X 3 , 01-03 , 01-04 , 11/27X 2 NGTD . Catheter tip 01-05 , NG . C. Diff B - negative Tunnled catheter tip 01-08 - ngtd HERPES SIMPLEX VIRUS PCR - PND Brief Hospital Course : A/P : 69 y/o female wtih PMH significant for ESRD on HD , type 2 DM , and recent PE resulting in PEA arrest admitted through the Juan with sepsis of unknown etiology . 1. Sepsis / ID- Started on sepsis protocol . Unclear etiology headache over the three days prior to admission in association with fever was concerning for a CNS etiology . Covered broadly with vancomycin , flagyl , and cefipime . Given stress dose steroids empirically and Sanchez stim showed cortisol of 9.3 --> 10.3 therefore steroids continued . CXR , LP , UA and abdominal CT showed no sign of infection . PICC line was removed empirically . Tip could not be cultured due to contamination . Cultures drawn off the HD cath are negative to date . Patient 's LE ulcers appear chronic and do not appear to be the source of infection . Her left knee is slightly erythematous compared to the right but not impressive . Joint is mobile . Nasal washings for influenza were negative ; culture pending . Patient improved over the next few days . Steroids were discontinued . On 12-18 flagyl and cefepime were discontinued as all culture data negative to date . Plan to continue vancomycin for 08-19 day course to treat empiric line infection . Urine culture came back positive for VRE , however , since patient improved without treatement ( ie Linezolid ) initially . After transfer to the floor when she was stable . On the floor the Vancomycin was discontinued as the catheter tip culture was negative . ID was consulted who suggested broad spectrum antibiotics if she were to spike . When pt spiked a temperature and became hypotensive she was started on Linezolid was started for presumed VRE infection in the urine . She will be treated for total 14 day course . She was also started on fluconazole for yeast in the urine , to be treated with fluconazole for total 7 days . She was given Flagyl for presumed C. Diff. Colitis , however this was stopped when C. Diff B toxin came back negative on 2019-01-10 . The tunneled catheter line was changed over a wire and the tip was also negative . 2. Respiratory - Intubated for airway protection due to change in mental status . Extubated 12-28 with no incident . 3. ECG changes - Patient had an episode of chest pain during her hospital stay that was both right and left sided with no radiation and no associated symptoms . ECG showed new diffuse TWI in all leads . Cardiac enzymes were cycled and were normal . Echo was obtained which showed WMA and EF of 35-40% . Pt was note started on ASA as she does not tolerate this well , BB was also not started given SBPs in the 110s . Statin was also deffered . She may be started on ASA , BB , statin by PCP as Stephen . 4. Shoulder fracture - Patient is s/p a left hip fracture ( decision not to operate ) and a left shoulder fracture with hemiarthroplasty 11-14 . Patient was found to have a new humerus fracture distal to the hardware on film this admission . Assumed to be secondary to trauma when moving patient into ambulance . CMED service was consulted and recommended wtd woulnd care and sling at all times . Wound care should be continued as described after discharge . 5. Type 2 DM - Patient was initially covered with an insulin drip while septic and then transitioned back to insulin sliding scale . 6. ESRD on HD - Pt has ESRD secondary to her DM and is on HD . She was dialysed but was slightly limited by hypotension . Dialyzed 12-28 with plan to dialyze again 12-31 . Her dialysis was managed by renal service in house . 7. PE ( 11-14 )- On heparin drip . Restared coumadin on 12-29 . Heparin discontinued on 01-01 when INR was 2.0 . Coumadin was stopped and she received fFP for tunneled line change over a wire . Coumadin was restarted at a dose of 2 mg qhs . This should be titrated after discharge for INR goal of 2-3 . 8. PVD : Dry gangrene of toes bilaterally w/ necrosis of the heels and posterior calf . Continue to monitor for sign of infection . On vit C. and zinc as well to aid w/ wound healing . Wound care consult given anasarca to prevent decub . 9. Left UE markedly more edematous than right UE , this could be from fracture , or there could be a clot , an abscess in the area also a possiblity . Ultrasound without clot . Continue elevation and tight dressing to LUE > 10. Access - Left IJ placed 12-26 in Juan was discontinued during the hospitilization . Right dialysis catheter ( 2018-11-05 ) was changed over a wire 2019-01-08 . PICC line placed 2019-01-08 , this should be discontinued immediately after pt finishes the linezolid course . 11. Code status - Initially full code then made DNR / DNI after family meeting on 02-27 . Made full code again on 12-30 after family meeting with son . Larry would like everything done . 12. Communication - With pt 's son . His name is Andrea and his phone number is 794 1029 x. 1385 . Medications on Admission : 1. Ascorbic acid 500 mg BID 2. Folic acid 1 mg daily 3. Humulin insulin 2 units QAM 4. RISS 5. Pantoprazole 40 mg BID 6. Neutra phos 2 tabs BID 7. Vitamin B complex 1 tab daily 8. Coumadin - Dose unknown 9. Tylenol 650 mg Q4H PRN 10. Ondansetron 4 mg Q6H PRN Discharge Medications : 1. Ascorbic Acid 500 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) . 2. Folic Acid 1 mg Tablet Sig : One ( 1 ) Tablet PO DAILY ( Daily ) . 3. Zinc Sulfate 220 mg Capsule Sig : One ( 1 ) Capsule PO DAILY ( Daily ) . 4. Acetaminophen 325 mg Tablet Sig : 1-2 Tablets PO Q4-6H ( every 4 to 6 hours ) as needed . 5. Papain - Urea 544 287 0616 unit - mg / g Ointment Sig : One ( 1 ) Appl Topical DAILY ( Daily ) . 6. Ipratropium Bromide 0.02 % Solution Sig : One ( 1 ) Inhalation Q4H ( every 4 hours ) . 7. Calcium Acetate 667 mg Tablet Sig : One ( 1 ) Tablet PO TID W/ MEALS ( 3 TIMES A DAY WITH MEALS ) . 8. Metoprolol Tartrate 25 mg Tablet Sig : 0.5 Tablet PO TID ( 3 times a day ) : Hold for SBP < 100 , HR < 60 . 9. Fluconazole 200 mg Tablet Sig : One ( 1 ) Tablet PO Q24H ( every 24 hours ) for 2 days . 10. Insulin Regular Human 300 unit / 3 mL Insulin Pen Sig : as directed Subcutaneous four times a day : Please administer 8 units glargine at dinner and regular insulin sliding scale as prescribed . 11. Warfarin 2 mg Tablet Sig : One ( 1 ) Tablet PO HS ( at bedtime ) : Titrate dose to Goal INR 03-15 . Tablet ( s ) 12. Linezolid 600 mg IV Q12H 13. Heparin Flush PICC ( 100 units / ml ) 2 ml IV DAILY : PRN 10 ml NS followed by 2 ml of 100 Units / ml heparin ( 200 units heparin ) each lumen Daily and PRN . Inspect site every shift . 14. Heparin Flush CVL ( 100 units / ml ) 1 ml IV DAILY : PRN 10ml NS followed by 1ml of 100 units/ml heparin ( 100 units heparin ) each lumen QD and PRN . Inspect site every shift 15. Dolasetron Mesylate 12.5 mg IV Q8H : PRN 16. medication Please complete a total 14 day course of linezolid . Stop linezolid on 2019-01-17 . The PICC line should be discontinued promptly after the linezolid course is completed . Discharge Disposition : Extended Care Facility : Newton-Wellesley Hospital for the Aged - Acute Rehab Discharge Diagnosis : Sepsis -? source Chronic Kidney disease - on hemodialysis type 2 diabetes hypercholestrolemia anemia of chornic disease h/o PE , s/p PEA arrest 11-14 Discharge Condition : Stable Discharge Instructions : You were admitted with low blood pressure and fevers likely due to an infection . Although there was never any bacteria isolated from the blood you had some bacteria in the urine which you are being treated for . It is important that you complete the antibiotic course as prescribed . Please continue to take all medications as prescirbed and follow up with all your appointments . If you have chest pain , shortness of breath , diahrrea or fevers please contact your PCP . Robert the shortness of breath gets worse please return to emergency room . If you have fevers please contact your PCP or return to the emergency room . Followup Instructions : Please call ( 664 ) 369-9786 to set up an appointment with your primary care doctor Dr. Andrew Shelton in 1-2 wks after discharge . Cleveland Barbara MD 00-732 Completed by : Sharon Frank MD 75-572 2019-01-10 @ 1333 Signed electronically by : DR. Janice Oconnell on : Kent 2019-01-10 3:28 PM ( End of Report )