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Inpatient Project

Inpatient Project. Heval Mohamed Kelli, MS-III Family Medicine, Rotation I August 23, 2009. Mrs. T .B. - an 51 y/o CF . CC: Allergic rxn to Brazilian nuts and right leg swelling. HPI: A dmitted 7:30 AM 8/16/2010

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Inpatient Project

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  1. Inpatient Project Heval Mohamed Kelli, MS-III Family Medicine, Rotation I August 23, 2009

  2. Mrs. T.B. - an 51 y/o CF CC: Allergic rxn to Brazilian nuts and right leg swelling. HPI: Admitted 7:30 AM 8/16/2010 6:00 AM allergic reaction to Brazilian nuts on flight from Brazil to Houston Within 30 secsof nuts intake: • SOB • unable to talk and swallow • face swellin • tingling sensation in hand spread to body On flight physician administred: • 1 amp sq epi1:1000 • 2X 50 mg Benadryl • Proair She regained ability to breath. 30 minutes later she was able to talk with difficulty of swallowing. Similar incident occurred 14 yrs ago.

  3. HPI: R leg swelling started 14/8/2010- less currently Feeling of heaviness, swelling, redness and non-radiating pain 10/10 Fever 102.5 F Alleviated: leg elevation, cold pack application Aggrevatd: sitting upright and movement Clindamycin300 mg oral tid recommended by PCP Last similar incident: worse, Dec 2009- Hospital 9 days on IV vancomycin. (Dx: cellulitis)

  4. PMH: 1998-Cervical Cancer- treated with surgical removal and radiation. 2006- Annual recurrent cellulitis– Diagnosed 2006- recurrent episode of lymphedema Childhood Illnesses: Anemia-iron deficiency 14 yrs old-resovled No any other major illnesses as a child Immunizations: + Pneumo and Flu vaccine. - H1N1 vaccine. Screening Tests:up to date with her annual exams and mammograms Accidents/Injuries: None

  5. PSH: 1996-Benign thyroid growth removal 1998-Pelvic lymph node removal due to cervical cancer 1998-Hysterectomy

  6. Medications: Clindamycin300 mg PO three times a day since 8/14/2010 Multivitamins-once a day Grape fruit seed-once a day Probiotic-once a day Allergies:Brazilian nut, almonds and penicillin.

  7. Social History: Occupation: Church program ministry assistant Living Situation:Lives with 17 years old daughter with her husband of 18 years marriage. Alcohol: None Tobacco: None Substance Use: None Diet: Eats three healthy meals daily which consist of fruits, vegetables, fish and chicken. Avoid intake of red meat, salt and sugar. Exercise: 5 times a week for 45 minutes (swimming and cardio exercises)

  8. Family History: Father-69, deceased, hypertension, heart attack Mother- 63, deceased, heart attack Sister- 54, alive, hypertension and chronic asthma Brother- 53, alive, recurrent diverticulitis. Brother-52, alive and well.

  9. Review of Systems: General– No weight change, appetite, fevers, chills, sweats, heat/cold intolerance, anemia Female genital—Menopausal, sexually active. Extremity/Musculoskeletal/Vascular – See HPI No arthritis, injury or trauma, varicose veins, phlebitis, bruising or bleeding, claudication Neurological-Unsteady gait due to painful sensation in right leg. She has some trouble with balance. No falling, loss of consciousness, blackouts, fainting, paralysis, numbness or loss of sensation, tingling, “pins and needles” Psychiatric- She feels optimistic and keeps a positive outlook on life. All Other Systems - Unremarkable findings.

  10. Physical Exam: Vital Signs Pulse 82 BP 109/62 Resp 20 T-97.9 F (oral) O2 sat 96% Weight: 150 IbHeight: 5’ 8’’ BMI: 22.8 General –WNWD thin Caucasian female lying in bed, uncomfortable due to right leg swelling and IV in left arm, appears stated age, good disposition. Chest- no tenderness; good chest expansion, both lungs clear to auscultation; no chest wall deformity; No wheezes or rubs appreciated. CVS-- RRR, Normal S1, S2; no murmurs, rubs, or gallops; no prominent neck veins or JVD noted. Extremities—3+ pitting edema with warm sensation and redness in right lower extremity up to ingunial ligament . 22 cm- width of right thigh. Limited ROM due to tenderness. Normal CRT. Pulses intact peripherally Pulses PT DP R 2+ 2+ L 2+ 2+ Neurologic - alert, awake, oriented x 3, no gross neurological deficit. Reflexes:biceps 2+, triceps 2+, knee 2+, Achilles 2+ equal and symmetrical. Negative Babinski. Sensation:warm and pain 7/10 in right leg Strength:Right leg 4/5, remaining proximal and distal muscle 5/5 equal and symmetrical Unsteady gait Psychiatric - affect and mood—euthymic, Thought and speech—coherent, grossly normal cognition

  11. Labs 133 L 99 13 13.2 17.2H 128 H 113 L 3.5 26 0.7 37.3 L

  12. Problem List • Anaphylactic reaction to Brazilian nuts • Erythematous, painful, pitting edema of right leg • Leukocytosis- Neutophillia • Lymphocytopenia and Monocytopenia • Thrombocytopenia • Hyponatremia

  13. Anaphylactic reaction to Brazilian nuts: The acute symptoms were resolved. Plan • Will monitor the patient for 24 hours. • Will educate the patient about carefully checking food labels to avoid future reactions. • Will have the patient to follow with her PCP

  14. 2. Erythematous, painful, pitting edema of right leg DDX: -Cellulitis, -Deep venous thrombosis -Superficial thrombophlebitis Plan: • Will order Doppler ultrasonography to rule our DVT • Will order blood coagulation studies to assess her for DVT and superficial thrombophlebitis. • Will start on DVT prophylaxis- Heparin 5000 U SQ q8h for now until diagnosis is confirmed. • Will start the patient on IV Vancomycin HCL 15mg/Kg every 12qh. • Will switch to oral antibiotic Bactrim DS orally BID until patients improves and discharge when less intense erythema, settling pyrexia and improvement of symptoms.

  15. Plan (cont.) • Will provide analgesic-Vicodin 1-2 tablets PO every 6 hours as needed • Will allow the right leg to be elevate to alleviate swelling. • Will educate the patient about prevention of cellulitis- clean and cover future wounds, support stockings and appropriate treatment of tineapedis. • Will provide the option of prophylaxis for recurrent cellulitis- Erythromycin 250mg bd for up to 2 years. • Will have patient follow-up outpatient with PCP

  16. 3. Leukocytosis- Neutrophilia DDx: -Acute infection -Acute glomerulonephritis -Leukemia-CML -acute MI Plan • Will have patient follow-up outpatient with PCP to reassess WBC differential. • Will have patient repeat complete blood count once the Cellulitis is resolved to reassess.

  17. 4. Lymphocytopenia/monocytopenia DDx: -AIDS -Aplasticanemia -Acute infection -Treatment with glucocorticoids -Hairy cell leukemia and AML. Plan • Will have patient follow-up outpatient with PCP to reassess WBC differential. • Will have patient repeat complete blood count once the Cellulitis is resolved to reassess the lymphocytopenia and monocytopenia • Will take a more thorough history to assess risks for acquired disorders, infections and long term effect of previous cervical cancer treatments.

  18. 4. Asymptomatic Thrombocytopenia DDx: Defective platelets production -Aplasticanemia, -Leukemia and -viral infection such as IV Platelets destruction -Idiopathic thrombocytopenic purpura (ITP) -Thrombotic thrombocytopenic purpura (TTP) -Hemolytic-uremic syndrome (HUS) -Disseminated intravascular coagulation (DIC) Plan • Will order blood coagulation studies, bleeding time and evaluate INR. • Will continue to monitor patient • Will repeat CBC to reassess risk after the Cellulitis is resolved.

  19. 4. Asymptomatic mild Hyponatermia DDx: -Hypervolemichyponatremia (Increased total body Na with a relatively greater increase in TBW) is commonly due to heart, kidney or liver failure. -Euvolemichyponatremia (Increased TBW with near-normal total body Na) is commonly due to Primary polydipsia, SIADH, Addison‘s disease, cancer or certain medications such as diuretics. -Hypovolemichyponatremia, Decreased TBW and Na, with a relatively greater decrease in Na) is commonly due to GI, renal or 3rd space losses. Plan -Will recheck serum electrolytes and order urine electrolyte including urine Na, FeNa after administration. -Will order Urine Cr and BUN and kidney function test. -Will assess patient’s volume status to determine type of hyponatermia and treat accordingly.

  20. Info from PCP -Her history of cellulitis? Managements? -The record of last hospitalization? -Dermatology visits and screenings? -Herbal medicine records?

  21. Psychosocial Circumstances Family • Impact of recurrent condition on family and activities • Preparation for future attacks • Anaphylactic emergency kit and usage Habits/traveling • Effect on exercise and daily activities • Limitation on traveling • Preparation Employment: • Ability of working • Choice of work environment Finances • Is she able to afford her doctor’s visits and medications?

  22. Psychosocial Circumstances Patient’s knowledge of disease • Patient desire for more education about her health • Understanding of lymphedema and its relation to cancer treatments. • Education on cellulitis prevention Herbal medicine • Knowledge about purpose and side effects • List herbs and learn about drug interaction • Respect the patient’s desire for alternative treatment

  23. Resources for Patient Familydoctor.org Emergency Anaphylaxis advice http://familydoctor.org/online/famdocen/home/common/allergies/basics/809.html American Cancer Society http://www.cancer.org Cellulitis prevention http://www.mayoclinic.com/health/cellulitis/DS00450/DSECTION=prevention Herbal medicine database http://naturaldatabase.com

  24. Discharge planning -Have patient follow up with PCP on current conditions and repeat CBC. -Continue oral antibiotics . -Refer the patient for dermatology consult.

  25. Thank You Questions

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