Stephanie Piemontese PharmD Candidate 2010 University of Pittsburgh School of Pharmacy

1. Patient Case Presentation:“Right-sided flank pain, acute mental status changes and shortness of breath” Stephanie Piemontese PharmD Candidate 2010 University of Pittsburgh School of Pharmacy September 24, 2009

2. Chief Complaint • Shortness of breath, mental status changes, and right-sided pain in abdomen and flank

3. History of Present Illness • 59 yo female • Some right-sided pain off and on since she fell and broke her pelvis last March • worsened • IV fentanyl with some relief per EMS • Denies trauma to the area • Hx kidney stones • Obviously hyperventilating, difficulty breathing when came into ED • Could slow down rate when asked

4. History of Present Illness (cont’d) • Abnormal speech • Not slurred • Problems with taking some medications • took 4 Zyprexa instead of 1 • Mix-up medications • Denies intentional ingestion of any substance out of the ordinary • Denies chest pain, nausea, sweats, radiation, or discomfort anywhere other than right flank

5. Past Medical, Social and Family History • PMH: • Bipolar Disorder • HTN • Substance Abuse • Chronic Pain (? Osteoporosis/Fibromyalgia) • Migraines • SH: • Quit smoking 1-5 years ago, denies EtOH/drug use • FH: • None specified

6. Home Medication List and Allergies • Clonidine 0.1mg PO TID • Colace 100mg PO BID • Remeron 45mg PO HS • Zyprexa 20mg PO BID • Prilosec 20mg PO AC breakfast • Seroquel 600mg PO HS • Allergies: • fluoxetine (hallucinations) • ketorolac (migraine exacerbation) • prochlorperazine (migraine exacerbation) • butorphanol (migraine exacerbation) • sumatriptan (migraine exacerbation) • sulfamethoxazole-trimethoprim (thrush)

7. Review of Systems • General: No fever/chills • Neurologic: No stroke/seizure • EENT: No sore throat • Cardiovascular: No chest pain/dysrhythmia • Respiratory: Clear breath sounds, hyperventilating • GI: Mild right lower quadrant abdominal pain, but more right flank pain • GU: No urgency/frequency/hematuria • Musculoskeletal: Chronic pain in right arm and hip from fall last March • Rest of review is negative

8. Physical Exam • Vitals: Temp 97.6°F HR 115-120 bpm RR 32bpm O2Sat 96-99% (room air)BP 112/51 mmHg • Weight 56.8kg • HEENT: normocephalic, no sign of trauma. • Eyes: EOMI. PEERLA. No nystagmus. • Oropharynx: normal • Neck: Supple • Chest: symmetrical • Lungs: clear • Heart: regular, tachycardic • Abdomen: soft

9. Physical Exam (cont’d) • Extremities: no edema • Skin: free of rash • Back: no CVA pain • Neurologic: non-focal with normal cranial nerves • normal finger-to-nose coordination, downgoing great toes • equal grip strength • follows commands • Psychiatric: awake, alert, and oriented x3 • Speech is somewhat pressured and she mumbles, but it is not slurred. If you listen carefully enough she is quite intelligible.

10. Labs • Included a BMP that showed normal electrolytes except for CO2 of 4. • BUN 28Cr 1.4 Glucose 90 Ca 10 WBC 14.9 H&H 13.6 &41.6 Plt 340 INR 1.2 • D-dimer0.31 • Troponin normal • Urine Tox screen positive for tricyclics • Blood Gas • pH 6.94 pCO2 11.5 pO2 236 HCO3 2.4 O2Sat 97% Anion Gap 24 • Head CT negative per radiology for any acute abnormalities • Abdominal CT and is negative for acute abnormalities other than a question of constipation • Sub acute fracture was noticed in the right symphysis pubis where she was fractured in the spring

11. Toxicology • Acetaminophen – <0.2 ug/mL • Acetone - 27 (8 mg/dL acetoacetate) • Salicylate - 8mg/dL • Urine positive for TCAs • Ethanol - negative • Isopropyl - negative • Methanol - negative • Ethylene Glycol -negative • Urine – negative for • BZDs, cocaine, opiates, cannabis, phencyclidine

12. Problem List • Acute • Metabolic acidosis • Compensating respiratory alkalosis • Acute Pancreatitis (lipase 2316 Units/L, amylase 901 IU/L) • Macrocytic anemia (MCV 113 fL) • PNA (MSSA, developed day 5) • Chronic • Bipolar Disorder • Chronic Pain Syndrome • Migraine • HTN

13. Metabolic acidosis • Sodium bicarbonate drip • Intubated • Fomepizole • 800mg IV load, then 500mg q 12 hours • Resolved within 12 hours of admission

14. Acute Pancreatitis • IV nutritional support • By discharge (day 12) lipase 848 Units/L and amylase was last noted at 101 IU/L

15. Macrocytic Anemia • Hbg 13.6g/dL  8.9g/dL over admission • Cyancobalamin 1,000 mcg IM injection • Not found to have vitamin B12 deficiency or folic acid deficiency • Plan • Follow up with PCP

16. MSSA Pneumonia • 5th day of admission noted possible left-sided effusion on Chest XR • Complaining of cough • Started on Unasyn 1.5g IV q 6 hours on day 6 • Sputum cultures from day 3 grew out MSSA • Therapy switched to PO Augmentin 875mg BID (total 10 days therapy)

17. FAST-HUG • Feed: • appropriate nutrition • Analgesia: • APAP 650mg q 4-6 hours • Sedation: • propofol 15mcg/kg/min , PRN lorazepam 1mg IV q 2h for anxiety • DVT/PE prophylaxis: • heparin 5,000 units SC q 12 hours • Head-above-bed elevation: • unknown • Stress Ulcer prophylaxis: • IV Pepcid 20 qd PrevacidSolutab 30mg NG qd  Prilosec 20mg ACbreakfast • Glucose Control: • Covered with sliding scale insulin

18. Bipolar Disorder • Continue • Zyprexa 20mg BID • Seroquel 200mg HS and 50mg q 1 a.m. and q afternoon • Remeron 45mg HS • Seek psychiatric evaluation and counseling • Supportive family

19. Hypertension • Continue • Clonidine 0.1mg TID • Follow up with PCP • Consider alternative medications • diuretics, ACEIs, beta-blocker

20. Chronic Pain and Migraine • Chronic Pain: • Evaluated for Fibromyalgia • Evaluated for Osteoporosis • Migraine: • Non-pharmacologic therapies • Beta-blocker

21. General Health • Counseled on medication management • Vaccines • Influenza • Pneumococcal (received inpatient) • Exercise – 30min/day, 3 days/week increase as tolerated • Evaluated for diabetes mellitus • Continue • Colace 100mg TID • High fiber diet