tokens: Admission Date : 2013-12-24 Discharge Date : 2014-01-13 Date of Birth : 1959-12-16 Sex : F Service : MEDICINE Allergies : Haldol / Compazine / Phenergan / Tigan / Flagyl Attending : David U. Johnson , M.D. Chief Complaint : Chest Pain Major Surgical or Invasive Procedure : Removal of tunneled cath ( previously used for tPN ) History of Present Illness : 54 yo F with Crohn 's s/p ileostomy and subsequent short gut syndrome with port-a-cath placement for TPN who presents with progressive right sided chest pain that comes in waves . The pt reports sharp 10/10 chest pain under the right breast which is getting progressively worse . The pain is worsened with deep inspiration or movement . It initially started one day previously but has gotten significantly worse over last 12 hours . It is associated with SOB as well as fevers , chills . The pt denies abd pain , n/v or increased ostomy output . Given her fever , sx of chest pain and SOB as well as an elevated WBC count , she was initially thought to have a PNA . She was therefore given ceftriaxone 1 g IV x1 and azithromycin 500 mg PO x1 in the Deanna . As the CXR was without any evidence of PNA , or PTX , the pt subsequently received a CTA to evaluate for PE which revealed multifocal bilateral PNA but no PE . At this time , she was given Vancomycin 1 g IV x1 . She was also given morphine 2 mg x3 , 4 mg IV x2 , dolasetron 12.5 mg x2 and ativan 1 mg IV x1 . Past Medical History : 1. Crohn 's disease , dx 1974 s/p three bowel resections and eventual ileostomy , resulting in short gut syndrome 2. Restless leg syndrome 3. ? Parkinsons vs. EPS side effects from risperdal 4. Chronic idiopathic pancreatitis , as demonstrated on CT in 09-01 5. Arthritis s/p " pin placement " in left foot 05-01 6. Degenerative disc disease s/p two back surgeries in 80 's 7. Benzo and opiod addiction 8. Paranoia / Depression , h/o auditory hallucinations , ? mania 9. Port-a-Cath placement for IV hydration in setting of short gut syndrome , complicated by clotting x 4 , requiring replacement Abd CT performed 09-01 showed multiple calcifications in the body and tail of the pancreas with a larger cystic lesion in the tail of the pancreas . A second 9 mm cystic lesion is seen in the head of the pancreas . These findings are consistent with chronic pancreatitis with pseudocyst formation Social History: lives w/ her husband in John area ; smokes 05-04 cig /d ( 30 pack year history ); no alcohol or recreational drug use , has had addiction to benzodiazepines and opioids in the past Family History : Mother-Crohn 's ; Daugher-IBS , colitis ; Mother -- breast CA ,; Father - Stephanie tumor , no DM , no CAD Physical Exam : V : 101.4 , 102 , 167/54 -> 159/77 , 24 -> 16 , 98% RA -> 96% RA Gen : middle aged obese female lying in bed on her left side asleep , speaking slowly . appears younger than stated age HEENT : PERRL , OP clear , MMM CV : RRR , s1 , s2 distant Chest : crackles at right base with dec. air movement . tender over right chest Abd : obese , multiple surgical scars . Ileostomy bag present with gas and stool . absomen soft , tender to palpation over RUQ , but no guarding or rebound Ext : tr edema , 2+ DP bilaterally Pertinent Results : 2013-12-24 01:30 AM GLUCOSE - 208 * UREA N - 21 * CREAT - 1.3 * SODIUM - 138 POTASSIUM - 4.2 CHLORIDE - 104 TOTAL CO2 - 23 ANION GAP - 15 2013-12-24 01:30 AM CK ( CPK )- 31 2013-12-24 01:30 AM cTropnT -< 0.01 2013-12-24 01:30 AM WBC - 14.4 *# RBC - 3.82 * HGB - 11.5 * HCT - 33.5 * MCV - 88 MCH - 30.2 MCHC - 34.5 RDW - 14.7 2013-12-24 01:30 AM NEUTS - 78.0 * LYMPHS - 17.0 * MONOS - 4.6 EOS - 0.3 BASOS - 0.1 2013-12-24 01:30 AM PLT COUNT - 128 * 2013-12-24 01:30 AM PT - 12.3 PTT - 26.1 INR ( PT )- 1.0 CTA 2013-12-24 - IMPRESSION : 1. No definite pulmonary embolism is identified . 2. Peripheral patchy opacities are seen bilaterally , most consistent with multifocal pneumonia . CXR 2013-12-24 - There are faint ill-defined opacities within the right lower lung zone and left upper lung zone could represent a multifocal pneumonic process . CXR 2014-01-02 - IMPRESSION : Multilobar pneumonia with interval worsening in the left lung but slight improvement in the right lower lobe . Head CT 2014-01-09 - Ordered to evaluate for changes to explain delta MS CONCLUSION : Left parietal subcortical hypodensity , likely ischemic . No definite changes since the MR of in 2011-05-15 . CXR 2014-01-09 IMPRESSION : Marked improvement . Brief Hospital Course : 54 yo F with Crohn 's disease s/p ileostomy with subsequent short gut syndrome with port-o-cath for TPN presents with acute onset pleuritic chest pain with fever , chills , and sob . 1. Chest pain / Fever / Chills : The acute onset of chest pain was initially very concerning for a PE , however the Chest CT demonstrated multifocal consolidation consistent with a bacterial PNA . This is consistent with the remainder of the pt 's history including fever , chills , sob and an elevated WBC count . The pt was given ceftriaxone / azithromycin / vancomycin in Deanna . Blood , urine and sputum culutres were sent . Pt 's blood cultures came back positive for Staph Aureus and Enterococcus , both were pansensitive . Sputum culture also returned with Staph. Aureus . Ceftriaxone and azithro were discontinued , and Vacomycin was continued . Pt initially was hypoxic requiring NRB for O2 sat of 94% , with any attempt to wean she would desat . Pt was intubated prior to tunneled catheter removal , see below . ( The tunneled catheter later came back for negative for culture. ) Earlier that day pt had a chest x ray which showed diffuse infiltrative process concerning for ARDS . Post procedure pt remained intubated on ARDSnet protocol . She self extubated the first day and was reintubated without any complications . Her O2 requirement improved on the vent over the next few days and she was weaned off the vent on 2013-01-01 . After extubation her o2 requirement was down to 1L NC with sats in mid 90s . She was transferred to the floor for further managment . The patient remained afebrile when she transferred to the medicine service . She was weaned off the oxygen and for the remainder of her course her O2sats were stable on room air . The patient had completed her antibiotic course while in house . 2. Hx of multiple port-o-cath clots : Although the pt is on warfarin chronically , her INR was subtherapeutic . Goal INR 01-31 . Initially coumadin was increased , however given concern for infected line , general surgery was consulted who removed the line in the ICU . 3. ARF : Pt initially with mild ARI , this was thought to be due to dehydration , after initial volume repletion her renal function improved to her baseline . 4. CMED : The pt has a history of paranoia / depression . ON admission she was taking Quetiapine 300 mg QHS and Clonazepam 1 mg QAM , 1 mg Q3PM , 2 mg PO QHS . Quetiapine was continued however clonipin was initially held when she was intubated on fentynyl / versed . This was restarted post extubation . Intially after being transferred from the ICU to the medicine service the patient was mentating appropriately . Her course later became complicated by visual and auditory hallucinations . She made disturbing comments to the hospital personnel . She was unable to sleep at night , often pacing the halls . She required a 1:1 sitter . Psychiatry was consulted . They felt that her presentation was secondary to delirium and was multifactorial . They attributed it to polypharmacy , recent infection ( pneumonia ) and insomnia . A head CT was done which ruled out any acute processes . The patient refused an LP . They made recommendations for adjustments to her anti-psychotic medications . At discharge the patient was on clonazepam 1 mg tid , seroquel 300 BID and neurontin 600 QAM , 1200 QPM and 1200 QHS . The Kindred Hospital hospital course was prolonged because of her delirium . Once her mental status improved she was discharged . 5. ? Parkinson 's Disease / Akithesia : The patient was maintained Sinemet . 6. Pain : In addition to her usual neuropathy pain , the pt initially appeared to have significant pain from the multi-focal PNA as well . ( Home regimen , Gabapentin 800 mg PO QAM , 1600 mg PO Q3PM , 1600 mg PO QHS . This was held in the ICU and she was given diluadid prn for pain control . The patient 's narcotic and CMED CCU regimen was evaluated by psychiatry during her delirium . Please see above for their recommendations . 7. FEN : Given her hx of ileostomy secondary to crohn 's disease and resultant short gut syndrome , the pt requires nutritional support via TPN . After removal of tunneled line pt was given tube feeds while she was intubated . The patient was transitioned to a low fat , low residue diet . 8 . PPX : PPI and heparin SC 9. Dispo : The patient was discharged home and instructed to follow up with her PCP . Louis follow up scheduled with psychiatry . Medications on Admission : 1. Quetiapine 300 mg QHS 2. Clonazepam 1 mg QAM , 1 mg Q3PM , 2 mg PO QHS 3. Ferrous Sulfate 325 PO Daily 4. Carbidopa-Levodopa 25-250 mg PO 5 TIMES PER DAY . 5. Gabapentin 800 mg PO QAM , 1600 mg PO Q3PM , 1600 mg PO QHS 6. Heparin Lock Flush 10 unit / mL Daily as needed . 7. Saline Flush 8. Prevacid 30 mg PO twice a day . 9. Vistaril 50 mg once a day as needed for nausea . 10. Zofran 4 mg PO once a day as needed for nausea . 11. Vitamin B-12 1,000 mcg / mL One Injection every other week . 12. Vicodin 5-500 mg 1-2 Tablets PO every six ( 6 ) hours PRN 13. Warfarin 1 mg PO HS . 14. TPN Discharge Medications : 1. Amylase-Lipase-Protease 33,200 - 10,000 - 37,500 unit Capsule , Delayed Release ( E.C. ) Sig : Four ( 4 ) Cap PO W/ MEALS AND SNACKS ( ) . Disp :* 120 Cap ( s )* Refills :* 2 * 2. Carbidopa-Levodopa 25 - 250 mg Tablet Sig : One ( 1 ) Tablet PO 5 TIMES A DAY ( ) . Disp :* 150 Tablet ( s )* Refills :* 2 * 3. Pramipexole 0.125 mg Tablet Sig : One ( 1 ) Tablet PO TID ( 3 times a day ) . Disp :* 90 Tablet ( s )* Refills :* 2 * 4. Clonazepam 1 mg Tablet Sig : One ( 1 ) Tablet PO TID ( 3 times a day ) . Disp :* 90 Tablet ( s )* Refills :* 0 * 5. Ferrous Sulfate 300 mg / 5 mL Liquid Sig : One ( 1 ) PO DAILY ( Daily ) . Disp :* 5 bottles * Refills :* 2 * 6. Nystatin 100,000 unit / g Cream Sig : One ( 1 ) Appl Topical BID ( 2 times a day ) . Disp :* 3 tubes * Refills :* 2 * 7. Lansoprazole 30 mg Capsule , Delayed Release ( E.C. ) Sig : One ( 1 ) Capsule , Delayed Release ( E.C. ) PO BID ( 2 times a day ) . Disp :* 60 Capsule , Delayed Release ( E.C. )( s )* Refills :* 2 * 8. Quetiapine 100 mg Tablet Sig : Three ( 3 ) Tablet PO BID ( 2 times a day ) . Disp :* 180 Tablet ( s )* Refills :* 2 * 9. Propranolol 10 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) . Disp :* 60 Tablet ( s )* Refills :* 2 * 10. Neurontin 300 mg Capsule Sig : Three ( 3 ) Capsule PO three times a day : take 2 tabs in the morining , 4 tabs in the afternoon , and 4 tabs in the evening . Disp :* 100 Capsule ( s )* Refills :* 0 * Discharge Disposition : Home with Service Discharge Diagnosis : Pneumonia Discharge Condition : Good Discharge Instructions : You are to return to the hospital immediately if you should experience any chest pain , shortness of breath , fevers or any other worrisome symptom . Please continue taking your medications as prescribed . Followup Instructions : Provider : Joyce , Catherine PSYCHIATRY CMED CSRU Phone :( 405 ) 582-6811 Date / Time : 2014-01-21 3:30 Please followup with your primary care physician Todd 12-30 weeks of discharge . Donna Mcguire MD 19-274 Completed by : Mark Joseph MD 04-104 2014-05-18 @ 2128 Signed electronically by : DR. Donna Nance on : WED 2014-06-04 2:21 PM ( End of Report )