Elective IM Rotation Notes
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Lake Erie College of Osteopathic Medicine *
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Medicine
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Apr 3, 2024
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Daily Rotation Notes
Elective: Internal Medicine
Questions about residencies at community osteopathic
What rotations are done in IM first year? o
4 internal, 1 elective, 1 gyn, 1 GS, 1 pulm, 1 cardio, 1 FM, 1 EM
What rotations are done in FM first year? o
2 internal, 1 ICU, 1 OB inpatient, 1 peds outpatient, 1 FM, 35 call shifts each year
How often do you go to the main Harrisburg hospital each year?
Does this program have fellowship programs joined to residency? How often do residents here go
into fellowship here?
For family med residency, how many residents typically go into hospitalist medicine each year? o
There are only 4 FM residents in each graduating class. Current 2
nd
years have a span of interests including sports med and addiction med. All current 1
st
years want to go into outpatient FM.
How many residents are there in each class year for IM residency?
What helped you get into the IM residency here?
What helped you get into the FM residency here?
Does the program care about grades, test scores, step vs comlex? o
No, most osteopathic or community programs will not have a strict cut-off here. Many programs are looking to see how you are as a colleague.
When does the residency start? How much time for orientation?
Dr. Sandhu contact – gurp4321@gmail.com
Dr. Brown contact – brownmx2@upmc.edu
Chart review strategies
1.
Check admission note to see why patient is in hospital to begin with
a.
Some patients have been there for a long time, so it may be necessary to review the most recent SOAP note for a brief summary of why they were admitted initially
2.
Write out the assessment and plan for each diagnosis a.
Use most recent SOAP note as a template b.
Make sure to add which depts are consulting and what that dept says
c.
For medications, write out what dosage they are given and confirm they were given it 3.
Write out lab values using fishbone charts for CBC and CMP a.
Make sure to point out trends of the labs
4.
Check nursing notes from previous night and see if there were any notable events 5.
Review medications 6.
What is your plan for the patient? 7.
Write a list of questions you want to ask the patient a.
Write out what physical exams you want to perform 02/05/2023 (Orientation)
Questions for residents
Does community osteopathic only accept DO residents? 02/07/2023 (Brown)
Pre-operative evaluation (Dr. Cruz)
4 things to consider o
Procedure being performed:
Consider if the procedure is high risk (CT surgery or neurosurgery), moderate risk (e.g. ortho surgery), or minimal risk
o
Meds patients are taking we need to watch out for:
Cardiac drugs such as diuretics, ACEIs/ARBs, and β-blockers
Keep beta blockers if patient is on them chronically
Hold diuretics in case of volume loss during surgery
Hold ACEIs/ARBs in case of volume loss during surgery
Diabetic medications
Hold short acting insulin because patient is not eating prior to surgery
Hold oral diabetic meds because patient is not eating prior to surgery
Blood thinners
Not always necessary to hold, depends on what surgery it is and what surgeon preferences are o
Acute conditions may impact hemodynamic changes during surgery:
Avoid surgeries in patients with recent ACS, acute CHF exacerbation, uncontrolled arrhythmias, new valvular disease
Consider ECG and echo with cardiology consult if concerned about these
issues
Lung conditions actually are not worrisome because patient is being intubated during the surgery anyways
o
Chronic conditions:
Diseases such as hyperlipidemia
CAD, diabetes, CKD, hx of stroke are all affected by blood flow, so surgery would be a hemodynamically stressful event for these patients
METS (questions related to ADLs and IADLs o
Ask questions such as how many city blocks can you walk, how much exercise can you do, can you dress/eat/etc.
RCRI (revised cardiac risk index) is used to assess pre-op risk for cardiac event after surgery 02/08/2023 (Brown)
Chart review strategies
8.
Check admission note to see why patient is in hospital to begin with
a.
Some patients have been there for a long time, so it may be necessary to review the most recent SOAP note for a brief summary of why they were admitted initially
9.
Write out the assessment and plan for each diagnosis a.
Use most recent SOAP note as a template b.
Make sure to add which depts are consulting and what that dept says
c.
For medications, write out what dosage they are given and confirm they were given it 10.
Write out lab values using fishbone charts for CBC and CMP a.
Make sure to point out trends of the labs 11.
Check nursing notes from previous night and see if there were any notable events 12.
Review medications 13.
What is your plan for the patient? 14.
Write a list of questions you want to ask the patient a.
Write out what physical exams you want to perform Charting patients
1.
Room 519: 74-year-old male with PMHx PVD, A-fib (on warfarin), HTN, HLD, GERD, osteomyelitis admitted on 1/31 for osteomyelitis, A-fib in RVR, PAD, supratherapeutic INR, and GP bacteremia. a.
Osteomyelitis R great toe and PVD R lower extremity 2.
Room 228: 62-year-old male with PMHx DM2, CVA, prev drug abuse, bladder cancer, bilateral TMA amputations admitted on 2/4 for osteomyelitis of L foot. a.
Osteomyelitis L foot Questions for attending
Why did we do an MRI brain w/o contrast on the patient in 228?
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What exactly is the procalcitonin used for? Do all patients with suspected bacterial infection get procal?
Vancomycin dosage per ID for patient in 228 is trough 15-20. What does this mean?
For patients who we don’t know any PMHx of, do we assess their meds and change them ourselves as hospitalists prior to discharge, or do we discharge them on all the meds they state they normally take?
Why does the first patient (519) have elevated platelets? Fast facts
Tricyclic antidepressants are not preferred for geriatric patients due to anticholinergic properties and risk of QT prolongation. If you must use tricyclic antidepressants, try nortriptyline first due to its lower risk of these adverse effects.
SSRIs can cause SAIDH, which presents on BMP as hyponatremia. Be sure to evaluate patients for signs of hyponatremia and understand that the SSRI might be the culprit. 02/09/2023 (Brown)
Chart review room 519
74-year-old male with PMHx PVD, A-fib (on warfarin), HTN, HLD, GERD, osteomyelitis admitted on 1/31 for osteomyelitis, A-fib in RVR, PAD, supratherapeutic INR, and GP bacteremia.
Osteomyelitis R great toe and PVD R lower extremity
Plan o
Continue recommended therapies by cardiology for A-fib o
Patient will have R leg AKA tomorrow (2/9) per vascular surgery o
Continue monitoring WBC, fever curves, CMP o
D/C antibiotics 48 hours after amputation Chart review room 228
62-year-old male with PMHx DM2, CVA, prev drug abuse, bladder cancer, bilateral TMA amputations admitted on 2/4 for osteomyelitis of L foot.
Osteomyelitis L foot
Plan o
Proceed with repeat I&D per podiatry (cardiac risk score is 1 (6% risk) – moderate risk for
moderate risk procedure
Chart review room 16
75-year-old black male PMHx GERD, T2DM, HTN, urinary incontinence, BPH s/p partial prostatectomy presenting with coffee ground emesis and dx in ED with PUD vs esophagitis. Presented to ED at 12:48 AM. Questions for attending
What is the importance of an elevated BUN and elevated creatinine if the ratio stays within normal limits?
Why did we do an MRI brain w/o contrast on the patient in 228?
What exactly is the procalcitonin used for? Do all patients with suspected bacterial infection get procal?
Vancomycin dosage per ID for patient in 228 is trough 15-20. What does this mean? o
Trough refers to a certain level in the blood we’re looking to maintain for that drug. So vancomycin (trough 15-20) means we’re watching that the levels stay between 15-20 in the blood.
Why does the first patient (519) have elevated platelets? Plasma cell disorders: Multiple myeloma (MM)
General features o
Neoplastic proliferation of single plasma cell line that causes excess production of monoclonal immunoglobulins, usually IgG or IgA
o
Almost all patients with MM have preceding monoclonal gammopathy of undetermined significance (
MGUS
) o
Typically occurs in older populations, twice as common in Blacks as in Caucasians
Classic features o
Remember mnemonic CRAB (hypercalcemia, renal failure, anemia, lytic bone lesions)
Bence jones proteins may appear as casts in the kidneys
renal failure
Anemia presents due to plasma cell proliferation overtaking bone marrow; fewer RBCs are produced as a result
Bones can undergo fractures and vertebrae may collapse causing shortened height o
Recurrent infections usually the worst issue and can cause death in 70% of patients with multiple myeloma Plasma cell disorders: Waldenström macroglobulinemia
Malignant proliferation of plasmacytoid lymphocytes that produce IgM para-protein o
IgM para-protein is very large and causes hyperviscosity of the blood
02/15/2023 (Sandhu)
Chart review room 432 Subjective
95-year-old female with PMHx paroxysmal atrial tachycardia (dx 2012), CKD (1.7-1.9), colovesical fistula, and recurrent UTIs
. Chart review room 529 Subjective
70-year-old male with PMHx of CAD s/p CABG, HTN, PVD, prior left AKA, T2DM, CKD3 with proteinuria, hypercalcemia, vitamin D deficiency presents with CC of hematemesis, encephalopathy, falls.
Treatment of sepsis in the ER (noon lecture)
3 treatments must be given within the first few hours of presenting to ER with sepsis o
Fluid resuscitation within first 3 hours
Use lactated ringers or normosol-R because these fluids have much closer solute
composition to normal serum; normal saline (0.9%) is more acidic than normal serum (5.5 pH vs normal serum pH is 7.5). Lactated ringers pH is 6.5 and normosol-R pH is 7.0.
o
Antibiotics + blood culture
Get blood cultures for both anaerobic and aerobic infections
Start abx within 4 hours because every hour delay for starting abx results in an 8% decrease in mortality
7-10 days of abx therapy is the most effective for sepsis o
Vasopressors within a few hours as well
Norepinephrine is first line vasopressor. Used to be dopamine, but SOAP II trial revealed dopamine use required norepinephrine anyways due to a new-onset arrhythmia.
Epinephrine and vasopressin should be considered if norepinephrine is contraindicated or does not work well
02/16/2023 (Sandhu)
Chart review room 529
Chart review room 402 My plan
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Overview of nonsurgical management of gallbladder stones - UpToDate
Table rounds
Patient in room 529 o
Daughter is listed in chart, but sister is main caregiver and stays with him at home.
Patient in room 402 o
Confirm DNR/DNI status because previously he was full code o
Nothing needs to be done yet about cholelithiasis/cholecystitis but if he does present with
symptoms, consider ursodiol and percutaneous cholecystostomy tube Teaching points
Heparin is used for DVT prophylaxis, not as treatment of superficial thrombi. o
Look up anticoagulation options for superficial venous thrombus in upper extremity
Patients at risk of respiratory compromise must be seen in ICU first for stabilization prior to admission onto medicine floor
02/17/2023 (Sandhu)
Chart review room 529 Chart review room 402 Teaching points
Be sure to check the input/output for patients on diuretics to see how much water weight they are losing. Check weight as well. Patient in 402 was down 2 pounds since yesterday and had net output 1.7 L yesterday, which shows diuresis is working.
Be sure to call into telemetry to assess current heart rate/rhythm.
New LBBB on EKG is critical condition and cardiology consult for potential STEMI treatment is the next best step.
Syncope Risk factors and causes
Cardiogenic problems: Orthostatic hypotension, electrolyte imbalances (e.g. hypoglycemia), tachycardia/arrhythmias, sick sinus syndrome, valvular issues (e.g. aortic stenosis), PE
Neurogenic problems: Vasovagal syncope, carotid hypersensitivity, spinal anesthesia
Workup
Head CT, EKG, telemetry, echo
CBC, CMP, UA, UDS
o
Could do D-dimer if suspicion for PE is high 02/20/2023 (Sandhu)
Chart review room ICU 3 Chart review room 208
Table rounds
Room 529 o
Hx renal cell carcinoma. 2 doses Eliquis for A-fib but patient had hematuria after this. o
Labs improving from yesterday. No input/output data. o
Urology wants to do what IR wants to do, IR taking him now for embolization. No surgical intervention at this time. o
Sudden increased WBC count with WBC spill into urine makes it potential UTI. Start him on antibiotics after urine culture.
Room 520 o
Last 3 weeks had 8-12 loose BMs and LUQ pain. Pos for C. diff. Decreased PO intake as
well, no vomiting but very nauseous. o
UA negative for UTI, elevated lactic acid now downtrended to 1.7. Viral panel negative. o
Plan: Continue PO hydration and IV if needed. Obtain viral load d/t hx of HIV.
Room 428
o
Hx of takotsubo cardiomyopathy secondary to stress from caregiver role. Went into A-fib and took metoprolol but did not improve; called cardio and recommended to come to ER.
o
Labs all normal, dopplers negative, EKG showed sinus tach, tele said sinus tach 120s but
no A-fib. Echo today.
o
Needs rate control as outpatient, consult cardio.
Room 420 o
Fluid overload returning at 315 pounds. Presented earlier in month and given lots of diuresis. Came in around this weight last time and dispo at 276. Workup was unremarkable last time so diuresis was key. Had pain control treated with dilaudid and PO medication, d/c last hospitalization. Discharged on 2mg Bumex. o
Started today on 2.5mg Bumex bid. Get troponins. Education topic: Clostridium difficile infection o
2 levels of severity o
WBC count 15k and creatinine >1.5 = severe C. diff
o
Shock, megacolon, ileus = fulminant C. diff o
Diagnosis done with PCR + confirmation test antigen testing o
First occurrence, treat with fidaxomicin or oral vancomycin o
Second occurrence C. diff use oral vancomycin again 125mg q6h x7 days
o
Third occurrence use oral vancomycin taper (qid x7 days
bid x7 days
qd x7 days
every other day x7 days)
o
Fourth occurrence use monoclonal antibody or fecal transplant o
Complications include toxic megacolon, ileus, shock
o
Manage toxic megacolon with surgery; ileus with bed rest and laxatives; shock with ICU 02/21/2023 (Brown)
Chart review ICU bed 3 Chart review room 208 Table rounds
Room 520 – C. diff
o
PMHx HIV, HF, HTN, cholecystectomy. Presented for prolonged course diarrhea and new
onset watery diarrhea. o
Imaging showed hepatosplenomegaly that is chronic. Chest Xray showed pneumonia vs atelectasis. On PO vanc for C. diff
. o
Today new onset excoriations in perineum? Wound care consulted.
Room 427 – LE cellulitis o
67-yo female PMHx A-fib. Cellulitis receiving Keflex but not improving. We started her on vancomycin, ID switched to ceftriaxone, dapto, doxy. Her legs were very red and warm to touch. Some pain with movement, working with PT.
o
BP low 100/64, thrombocytosis at 426.
Room 420 – full body swelling o
Lost 20 pounds since coming in. 310 at admission. Last time he was discharged home after dropping to 276 pounds. o
Give 1 more day of Bumex 2.5mg IV bid. Continue Tylenol prn. Continue monitoring intake/output.
o
Patient wants to go to rehab this time. Needs to f/u with PCP
02/22/2023 (Brown)
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Chart review room 528 Chart review room 207 Table rounds
Room 529 – Treating for PNA and UTI. On ceftriaxone and azithromycin. WBC now is 9.4, downtrending. Vitals stable and afebrile.
Room 520 – Significant diarrhea, 7-10 at baseline. Wants to go to rehab but is not a candidate because she is refusing PT/OT, is on suboxone, and is considered too healthy.
Room 427 – Currently on doxy and daptomycin. ID wants her to be discharged on PO linezolid (daptomycin is only IV). Linezolid is to be used for 14 days per recommendation.
Room 207 – F/U palliative care and contact son for discussion. Trend BPs and monitor PO intake.
Risk for aspiration pneumonia. Teaching points
Viibryd and other SSRIs carry a minor risk of GI bleed.
Steroids can cause hyperglycemia, leukocytosis, and elevated BP. In our patient, the BP did not budge even after dexamethasone was given. This implies there was another reason for the hypotension.
Type I diabetes can be secondary to pancreatic cancer because by definition, the progression of cancer kills off insulin-producing cells.
Linezolid is a weak MAO inhibitor, so counsel patients on signs of serotonin syndrome if prescribing this medication to them.
02/23/2023 (Brown)
Chart review room 207 Chart review room 407 Table rounds
Room 520 – C. diff patient. Currently has nausea but still eats about 1/3 breakfast this am. Labs WNL. Does not qualify for rehab, setting up with home health instead. Discharge her today.
Room 507 – Discharge home because his care is no better here at this point than at home.
Room 427 – Fatigued today. RLE has some edema, she states it gets better as day progresses. CBC values trending upwards, perhaps check for dehydration. Give 1L IV LR. Already given 1 dose of linezolid and tolerated it well. Afebrile and no significant white count. Ready for discharge.
Room 407 – Patient to be discharged because her COVID symptoms are mild, labs are negative, no antibiotics indicated, US for DVT negative.
Teaching points
PO magnesium for patient with low Mg will cause diarrhea. Be careful of this in patients with C diff
infections.
02/24/2023 (Brown)
Chart review room 207
Chart review room 212 Subjective
68 y.o. male with PMHx CVA in 2015 and again 2 weeks ago, at which time he was hospitalized (14-16) and found to be hypotensive. Also COPD, obesity, HTN, HLD, hyperthyroidism, MDD. Notably, patient is bedbound and stays at Blue Ridge Nursing Facility. Presents with altered mental status and hallucinations last night. In ED, patient had L sided weakness (since last CVA 2015), neck pain, diarrhea, SOB, dry mouth. He normally uses a nebulizer and CPAP at home but
he did not have this upon d/c from hospital, so he might have become hypercarbia and had these symptoms.
So far he has been negative for infection, UA at nursing home was negative for UTI 2 days ago, ammonia WNL, CBC/BMP/trops negative, EEG no changes, head CT on 2/23 shows previous CVA but no acute changes. ABG shows mild CO2 retention.
Unable to participate in interview. Not compliant with bipap at home. Suicidal ideation right now. Abdominal pain to touch, but no pain elsewhere. 02/27/2023 (Brown)
Chart review room 207
Subjective
70-year-old female with PMHx pulmonary blebs, throat cancer 2005, lung cancer 2007.
Overnight events – patient was unaware she is taking mirtazapine and wanted clarification o
Lips very chapped, can we give Vaseline? Objective
Questions for patient
Review of symptoms
Exam findings Assessment/Plan
Severe protein calorie malnutrition o
Nutrition is following. Patient refused dilation of esophagus.
o
PEG tube placed on 02/24 by Dr. Robinson
PEG positioned at 2 cm at the skin. Confirmation imaging for placement not necessary as it was placed under endoscopic guidance.
Started with isosource formula 1.5 at 15 mL/hr. Advancd to 45 mL/hr. Swtiched to
bolus yesterday as she was holding 45 mL/hr well. General surgery signed off of patient yesterday.
Can discharge once feeding equipment is available at home for patient
Platelets increased steadily since day her PEG tube was placed (297
322
373
405)
Creatinine steadily decreasing (today 0.37)
Hypotension, PNA, blebs – STABLE o
Continue abx, will discharge on Augmentin for 6 weeks, CT chest by pulm outpatient after
6 weeks and reassess for need for more antibiotics o
Pulmonology following and will continue outpatient Chart review room 212 Subjective
68 y.o. male with PMHx CVA in 2015 and again 2 weeks ago, at which time he was hospitalized (14-16) and found to be hypotensive. Also COPD, obesity, HTN, HLD, hyperthyroidism, MDD. Notably, patient is bedbound and stays at Blue Ridge Nursing Facility. Presents with altered mental status and hallucinations last night. In ED, patient had L sided weakness (since last CVA 2015), neck pain, diarrhea, SOB, dry mouth. He normally uses a nebulizer and CPAP at home but
he did not have this upon d/c from hospital, so he might have become hypercarbia and had these symptoms.
So far he has been negative for infection, UA at nursing home was negative for UTI 2 days ago, ammonia WNL, CBC/BMP/trops negative, EEG no changes, head CT on 2/23 shows previous CVA but no acute changes. ABG shows mild CO2 retention.
Unable to participate in interview. Not compliant with bipap at home. Suicidal ideation right now. Abdominal pain to touch, but no pain elsewhere. Objective
Assessment/Plan
Altered mental status o
Psych consulted and they believe this is delirium secondary to polypharmacy. Recommend d/c Depakote and duloxetine. Mentation significantly improved s/p medication changes. Continue venlafaxine, Ativan, oxycodone.
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o
Nursing noted yesterday afternoon patient mentation is improving. A&O x4, still has L limb weakness (chronic since CVA in 2015). OT did MoCA on this patient and found he scores 18/22, which is just below normal score. o
Hemoglobin trending down since admission (13.7
12.7
11.8). o
Patient is not happy with care at the nursing home. Chart review room 506 Subjective
100-year-old female with PMHx recurrent UTIs, hypertension, CHF, CKD 4, presented to ED with her son per Butler nursing home. Nursing home staff found patient unresponsive on 02/25. She was found to be hypoglycemic in ED and given dextrose. This improved her mental status but not
to baseline. Son states patient has not been eating much last 3 weeks and Lasix was recently increased by her PCP from 20 to 40 mg due to fluid retention. o
ED worked up AKI with creatinine 2.8 (baseline is 1.6), BNP 350. Chest Xray concerning for pulmonary edema, possible superimposed multifocal pneumonia. Respiratory viral panel negative. UA not significantly concerning for infection. Objective
Did not get to see patient Assessment/Plan
AKI and elevated BNP o
BMP reveals creatinine increasing (2.34
2.96
3.06
3.12), BUN increasing (51
62
68), GFR down to 13. – does this put her in stage 5? BNP 350 on admission. o
Input/output no results for yesterday. Today 300 mL output so far. Daily weight stays 152 between yesterday and today. o
Continue Bumex 1mg IV bid, BMP q12h, replete electrolytes as needed. Consult nephrology if worsening creatinine. Retroperitoneal US ordered. Echo ordered.
Retroperitoneal US reveals complex lesion in R kidney that could represent neoplasm or very complex cyst. f/u CT or MRI with and without contrast (renal mass protocol) is recommended.
CT head reveals no acute intracranial process, only age-related atrophy and chronic small vessel disease. Evidence of antecedent vascular insults in basal ganglia (lacunar infarcts?)
Pneumonia o
CBC reveals macrocytic anemia (RBC 3.22, Hgb 10.8, MCV 100)
o
Chest X-ray reveals worsening aeration throughout both lungs with increasing interstitial and airspace opacities. Worsening diffuse pulmonary edema. Superimposed multifocal pneumonia is on differential. Persistent bilateral pleural effusions left larger than right.
o
Continue ceftriaxone and azithromycin – did not meet SIRS criteria on admission but procal is elevated (0.5)
AMS o
Continue treating pneumonia with azithromycin and ceftriaxone. Repeat UA with reflex. o
Speech pathology saw patient. Noted mild oropharyngeal dysphagia without frank signs of aspiration. Patient dentures are loose fitting and may interfere with swallowing. Patient speech reduced as she mumbles and speaks fast. Recs are level 2 puree diet, thin liquids by cup or straw, feeding assistance, adhesive cream for dentures.
Gout, hypertension (chronic, continue home meds) Table rounds
Room 506 – Consult nephrology, talk to family about next steps.
Room 429 – One unit blood, SW will talk to her about dispo to Hellen Simpson. F/u with nephrology.
Room 428 – LLQ abdominal pain. Afebrile. One more day of antibiotics.
Room 214 – Admitted on Saturday. Was getting her nails done when she suddenly bent over, had
drooping on one side of face, slurred speech. Stable since she presented here. CT head negative. Tele shows she is normal sinus most time. Echo showed EF fine but bubble study inconclusive. MRI head negative. Discharge today to Ecumenical.
ED 19 – Hx CVA, CAD s/p stenting, presents with abdominal/chest discomfort. Have speech see her before starting new diet so they can assess her swallowing s/p CVA. Ceftriaxone for UTI.
ED 18 – Hx DVTs, morbid obesity, new onset A-fib. Chief complaint weakness in lower legs both. Couldn’t get out of wheelchair on weekend, very weak, came to ED. Teaching points
Antibiotics take 2-3 days to work. Making determination of whether or not to switch antibiotics must take this into account.
Supratherapeutic INR >8 you treat. Also if <7 and symptomatic, treat. Can use vitamin K, FFP, or Kcentra for treatment. 02/28/2023 (Specht)
Chart review room 526 Subjective
87-yo male with PMHx CKD3, PAD, AAA, angina, emphysema, HTN, HLD, prostate cancer. Presented to his PCP yesterday (2/27) with dyspnea and cough x1 month duration he attributes as COPD exacerbation. SOB while getting ready in morning, which is unusual for him. No COVID
testing done in this last month. Used home inhalers (Spiriva, Wixela) with minimal relief. Developed cough productive of clear sputum. No hemoptysis. o
PCP also notes ankle swelling and assessed his BNP and D-dimer. These came back elevated (BNP 1250 and D-dimer 5300), so the PCP sent patient to ED. o
Saturating low 80s and tachypneic on arrival. Put on 4L oxygen, saturated to mid-90s. Does not use oxygen at home. o
Patient said he may have been diagnosed with CHF in the past but is not on diuretics. Followed by cardiology Dr. Stuck. Patient also endorsed episodes of chest pain that radiate anteriorly from 1 shoulder to the other that resolve on their own.
ED course
o
Given duonebs, steroids, IV antibiotics which all improved his symptoms.
Cultures drawn pending, troponins negative (22
19
19).
CTPE was obtained – negative for PE. Moderate centrilobular emphysema. Small bilateral pleural effusions cause compressive atelectasis. Rounded solid mass in LLL, concerning for neoplasm. L hilar adenopathy or mass also concerning for neoplasm.
Recommended follow up PET-CT.
Overnight o
SPO2 88 on room air. Placed on 4L nasal cannula and PO2 rose to 98%. Took him off. Later in the night SPO2 88 again. 2L nasal cannula, PO2 rose to 94%
Outpatient meds include amlodipine 10mg qd, ASA 81mg qd, Plavix 75mg qd, isosorbide mononitrate 30mg qd, metoprolol succinate 100mg qd, Singulair 10mg tablet qd, nitroglycerin 0.4mg SL tablet qd, pravastatin 40mg qd, Spiriva inhalation capsule qd. Objective
Smoking hx? Assessment/Plan
Acute respiratory failure with hypoxia o
Possibly COPD exacerbation due to infectious cause.
CXR showed mild ground-glass infiltrates in perihilar and lower lobes. New lung mass noted on CT PE
. Procalcitonin pending. WBC 6.7. o
Steroids: 1 dose solu-medrol in ED, will continue prednisone 40mg daily x5 days. Abx: continue ceftriaxone x5 days and azithromycin x3 days SABA/SAMA: albuterol nebulizer, continue home inhalers Ox: continue nasal cannula as needed, goal is 88-92% Pulm consulted for new mass on CT PE – no note yet
Mass to lower lobe o
Obtain PET-CT for further evaluation of new masses seen on CT PE
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o
Pulm consulted
Elevated D-dimer
o
PE ruled out but may be due to mass
Elevated BNP
o
Last echo on 2/16 showed LV EF 45-50% and globally reduced LV function and ventricular ectopy.
o
Exam positive for mild pitting edema on bilateral lower extremities. Troponins negative. Holding home amlodipine, monitor bilateral LE edema
o
Received fluids yesterday today but no output yet. Weight yesterday 130 lbs
Acute-on chronic kidney injury o
Baseline creatinine 1.8, creatinine on admission 2.22 o
Likely pre-renal due to poor PO intake and recent contrast administration o
Monitor daily BMP
COPD o
Spiriva and wixela at home. Baseline O2 is room air,
PAD – stable
o
Home aspirin, Plavix, pravastatin
CAD with stable angina pectoris – stable o
Follows Dr. Stuck outpatient, continue aspirin, Plavix, pravastatin, prn nitroglycerin
HTN, anxiety, HLD – stable, continue
PREV MED o
DVT prophylaxis – subq heparin
o
Bowel regimen – miralax Chart review room 230
Subjective
68-yo male PMHx gout, HTN, NLD (ulcers on legs idiopathic), obesity, GERD. Presenting with urine leaking around Foley catheter, dysuria, fevers, chills. Requires interpreter during encounter. o
Recntly seen in ED for urinary retention and UTI on 2/18. Discharged with foley and ccefuroxime for 7 days to be completed on 2.24. Patient had worsening urination around Foley catheter the same day (2/18) after discharge .Also reports dysyuria and penile discomfort at that time. Fevers and chills since Saturday.
Other symptoms include pain and swelling in left knee (hx of gout) and recent indigestion. No SOB, chest pain, n/v/d. Does have chronic constipation.
ED course
o
Had foley removed at bedside and yet to urinate at time of interview. Blood cultures and urine cultures obtained. o
Started on ceftriaxone. Objective
Complains of gout pain in left knee. Also running temp. Colchicine and Tylenol given. Fluid bolus running.
Assessment/Plan
UTI
o
Completed PO antibiotic course on 2/25. (cefuroxime). o
SIRS criteria ¾. Source of infection UTI.
WBC 21.1 on admission. UA showed 1+ blood, 1+ protein, 3+ leuk esterase, 1+ bacteria, 16-30 RBCs, >50 WBCs
Lactic acid 1.1 (wnl)
CBC shows 17.4 WBC today (21 yesterday). Hgb low 9.3, trending down (10.3 y), hct down from 30.6 to 26.9 today. Platelets elevated but down trending since yesteryda, 637
553.
CMP. Na 131 y to 134 today. BUN and creatinine seem to trend high for him. 26 and 1.88 today. eGFR today 38. Past few months was around 40. o
Renal US
Showed small bilateral renal cysts, simple in appearance no follow up warranted.
Ill-defined echogenic focus in left wall of bladder.
No evidence of hydronephrosis or nephrolithiasis. Somewhat ill-defined and difficult to measure. Could represent area of calcification or shadowing mass in wall of bladder. o
Foley removed in ED. On ceftriaxone course of 7 days? Urology consulted to see if we need cystoscopy. o
Continue home tamsulosin, monitor for fevers, prn Tylenol ordered. o
Net output 475 yesterday and 400 today. Weight from 185 to 176 yesterday within a few hours, probably measurement error.
Urinary retention (because he has been here twice now) o
Nephrology consulted
CKD – follow nephrology
Gout o
Takes colchicine M/W/F at home. Also on febuxostat.
Pt complains of pain and swelling in L knee last night, also running temperature
Elevated CRP and ESR, uric acid 6.0 o
Continue home meds, prn Tylenol available. If woersens, consider prednisone
GERD o
Patient complains of gastric reflux on admission. Will continue protonix and PRN tums
Hypertension – stable, continue home meds (Norvasc and Lopressor)
HLD – diet controlled
Oesity – 30-34.9
Prev measures o
DVT prophylaxis home eliquis o
Full code o
Bowel regmine miralax
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