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MORBIDITY & MORTALITY CONFERENCE

MORBIDITY & MORTALITY CONFERENCE. LATA SHAH, MD VA MEDICAL CENTER ETSU. ADMISSION. Admitted on 6/7/02 Complaints Worsening shortness of breath since recent d/c on 5/30/02 Pedal edema x 1 week. PAST MEDICAL HISTORY. COPD (FEV1-58%) CAD, S/P CABG IN ‘92, HYPERTENSION,

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MORBIDITY & MORTALITY CONFERENCE

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  1. MORBIDITY & MORTALITYCONFERENCE LATA SHAH, MD VA MEDICAL CENTER ETSU

  2. ADMISSION • Admitted on 6/7/02 • Complaints • Worsening shortness of breath since recent d/c on 5/30/02 • Pedal edema x 1 week

  3. PAST MEDICAL HISTORY • COPD (FEV1-58%) • CAD, S/P CABG IN ‘92, HYPERTENSION, • H/O CHB S/P PACEMAKER IMPLANTATION • CHF WITH LVEF -35% (LATEST ECHO REPORT) • CHRONIC RENAL INSUFFIENCY ( BUN/CREAT: 22->30/1.6->2.6) • H/O ENTEROCOCCAL BACTEREMIA AND PNEUMONIA • H/O PEPTIC ULCER DISEASE AND LOWER GI BLEEDING • H/O DEPRESSION

  4. SOCIAL HISTORY • Former Heavy Smoker: • Smoked 2PPD for 45 years • Quit in 1990’s • Lives with wife

  5. OUT PATIENT MEDICINES • CARDIAC MEDS • Aspirin 81mg EC, Atenolol 25mg qd • Lasix 40mg po bid, Simvastatin 10mg • RESPIRATORY MEDS • Methylprednisolone 60mg bid • GI • Rabeprazole 20mg po qd • Multivitam and Calcium • ANTIDEPRESSANS • Sertralin 50mg po, Trazodone 50mg • ANTIBIOTICS • Levoflox, flagyl 500mg tid

  6. PHYSICAL EXAM ON ADMISSION • Weak elderly gentleman with stable vital signs • Raised JVD. • Bilateral lower extremities swelling 1 + • Respiratory: coarse bilateral rales up to mid thorax and bilateral expiratory wheezing . • Cardiovascular: NAD • Abdomen: Benign , Peg tube site clean . • Neurology : Non focal

  7. ADMISSION LABS • CBC:WBC-19.1/Hb-12.2/Plt-227 • BMP:141/4.2/103/29/22/1.6 • ABG:7.42/43/64/92.4--- 30% • EKG:Paced rhythm @70/mn • CXR:Consistent with COPD and CHF

  8. INITIAL ASSESSMENT/PLAN • Severe COPD with possible exacerbation: • Exacerbation of CHF • CRF

  9. INITIAL MANAGMENT • Rule out MI • Breathing treatments • Induce diuresis carefully • Panculture • Start antibiotics for COPD exacerbation, rocephine + zithromax

  10. HOSPITAL COURSE (1) • Patient’s condition remained stable for the first 3 days post admission , later on he complained of worsening shortness of breath and had decreased po intake • His blood pressure was 96/49 with a HR of 80/mn, advised to increase po intake, lasix was held. • Blood culture were positive for MRSA, patient was started on vancomycin, adjusted to renal function.

  11. HOSPITAL COURSE (2) • ID consult- MRSA bacteremia Cultures: blood/ sputum / urine • Cardiology consult- echo • General surgery consult- PEG tube

  12. TEE - RESULTS • Reduced LV function (EF of 25%) with possible apical thrombus • No evidence of vegetations on the aortic, mitral or tricuspid valve • Pacer wires were fairly well visualized in the RA and RV with no clear evidence of vegetations. • Mild AI, mild TR, mild PI. • Anticoagulation with Coumadin and lovenox-60mg sc bid started (6/13/02)

  13. HOSPITAL COURSE (3) • Patient was started on theophylline for COPD • Patient was also started on Coumadin for questionable organized LV thrombus

  14. DISCHARGE PLAN • No complaints • Vitals stable • Labs: INR 1.34 • Patient’s functional status did not improve much • Coumadin education completed

  15. DISCHARGE MEDS • Theophylline 100 mg sa bid • Lasix 20 mg qd • Warfarin 4 mg qhs • Lovenox 60 mg bid till INR therapeutic • Linesolide 600 mg bid for 3 weeks

  16. PLANNED FOLLOW UP • Coumadin clinic • Home anticoagulation management 6/17/02 with PT / INR • ID clinic- 2 weeks • IMC clinic with CBC , CMP , Theophylline level on 6/30/02

  17. PATIENT AT HOME 6/14 - 6/23 • Follow up with home health anticoagulation , reported INR was 4.0 (6/17/02) , warfarin dose was 5mg qd Lovenox was continued till 6/17/02 in am • Patient instructed to skip one dose of warfarin then alternate 5mg qd with 2.5 mg qd until he receives by mail Coumadin tab dosed at 4 mg then start 4 mg • Planned recheck INR in 7 days

  18. READMISSION (6/23/02) • Admitted to the on-call team over the weekend • New complaints: • sudden onset of hemoptysis x 2 upon awakening at 3 am with bouts of coughing, small amount with small clots • worsening shortness of breath • tarry stool since discharge from the hospital • no chest pain or fever

  19. READMISSION (2) • BP 107/60, P 85, RR 25, • Patient was in moderate distress. • HENT: slightly dry mucosa, some blood in the mouth, no JVD. • CVS: RRR,no murmurs or gallops. • Lungs: diffuse crackles R>L • Abdomen: soft, nontender, PEG tube was in situ, +BS • Ext:no edema. • Rectal exam: stool hemoccult positive, prostate exam was normal

  20. READMISSION (3) • CBC: wbc-9.1 (10.2) / Hb-10.3 (12.9) • BMP: bun/creat: 38/1.7 • INR: 7.67 (4.0 on 6/17/02) • ABG: 7.47/38/43/82% @ 32% • CXR: with bilateral infiltrates and left lower lobe opacities which are chronic.

  21. READMISSION (4) As per admitting team: Assessment & Plan • Hemoptysis in a pt with restrictive lung disease and Supratherapeutic INR. -drop in 2 gm of HGB last week. -get ABG & 3l O2 to keep sat >89%. Breathing Tx -will give 2 U FFP to reverse the effect of coumadin since pt is still having hemoptysis and melena. -will stop coumadin and theophyline. -H/H q8hrs

  22. READMISSION (5) 2) Melena: UGI bleed with HIGH INR. -FFP -Aciphex -H/H q8hrs.

  23. TRANSFER TO OUR TEAM (6/24/02) • AS PER ADMITTING TEAM: • Patient was hemodynamically more stable • had no more hemoptysis • Vitals : P-100/min, RR-28/min, BP-138/53 • Labs were pending for the morning • ABG - 7.43/35/49 at 36% FiO2 : on V-mask with increased O2 to 8L and sats improved to +90%

  24. REASSESSMENT AT THE BEDSIDE • No c/o hemoptysis, improved since admission as per wife and the patient. • Patient c/o worsening shortness of breath. • Vitals were stable. • Physical exam- patient was breathing at the rate of 28/min, BP138/53, afebrile, pulse 100 • systemic exam: Resp-bilateral rales heard up to mid thorex with wheezing • CVS-tachycardia noted, Abdomen-benign • Attending was informed about the transfer of the patient.

  25. REASSESSMENT (2) • Patient ‘s lungs exam sounded congested • As he was receiving NS at 75cc/hr and had received FFP 2units overnight. His IV fluids were stopped and lasix 40mg additional dose was given • Attending was informed about the transfer at around 9:15am and we started rounding from this patient

  26. MEASURES TAKEN • Blood transfusion planned and was in the process of ordering • Nurse called us at 10:50 am informing that Mr.Hill is c/o increasing shortness of breath. • While examining him we noticed that he had large black color bowel movement. • After that he started deteriorating within few minutes • Stat Breathing treatment ordered, repeat ABG was ordered

  27. MEASURES TAKEN • Lasix 40mg IV stat given • Repeat PCXR was ordered. • Ordered bedside pulse oximeter and tried to titrate up his FIO2 to 80% via V-mask to maintain sats around >88% • Lab informed us about Hb of 7.6; Dropped from 10.2 on admission(12.2 on 6/14/02)

  28. FURTHER COURSE • MICU was informed • Patient went in to respiratory arrest and died at 12:15 • Patient was DNR • Death was easily accepted by the family at the bedside. Patient was DNR

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