WORKUP

MIMIC Database Record 237

Admission date:20/07/1995
Discharge date:28/07/1995
Age at admission:62
Sex:F

History

Chief Complaint:

Patient was transferred to BI from an outside hospital for her second PTCA in the setting of acute IMI/RVMI.

Present Illness:

Patient w/ hx ischemic heart disease presented to outside hospital early in am of 20/07/1995 w/prolonged chest discomfort and SOB. On arrival at their EW she was in acute respiratory distress with evidence of IMI, CHF, and pulmonary edema. She vomited once after getting KCl. She may have aspirated at this time according to physicians. Her acute course was very complicated. She had a V fib arrest requiring 200 and 300J defibrillation, then transient CHB, then NSR. She was intubated emergently for respiratory failure. She was sent to BIH for further management. Emergency cath done at BIH, revealing elevated filling pressures, and diffuse CAD. She had PTCA x2 with stents placed in proximal and mid RCA w/ good result. She was transferred to the CCU for continuing care.

Past Illnesses:

CAD, S/P PTCA of RCA 7 yrs ago
hypercholesterolemia
HTN
Obesity

Social History

Marital Status:D
Habits:
Occupation:secretary (laid off 6 weeks ago)
Tobacco:Yes
Tobacco Notes:hx 1 pk/day x30 yrs. Quit 9 yrs ago
Alcohol:No
Alcohol Notes:
Drug Abuse:
Family History:Pt's brother died of MI at 64 y.o.
Pt's father died of MI at 50 y.o.
Mother died of Ca
Allergies:
Past Medications:Mevacor 20 mg bid
Diltiazem CD 180mg qd
Toprol - XL 100mg pd
Dyazide
Operations:S/P TAH
S/P cholecystectomy
Hospitalizations:

Physical Examination
Date of exam:20/07/1995
Height:167.6 cm (66 in)
Weight:127.3 kg (280 lb)
BSA:2.31 m²
Pulse: 74
Systolic: 120
Diastolic: 65
Temperature:37.8° C (100° F) Mode: R
Respiration:14
General appearance:Lethargic, obese white female
Skin:
HEENT:pupils equal, reactive; anicteric sclerae
Neck: 2+ symmetric carotid pulses
no bruits, no ostensible JVD, no oropharyngeal lesions
Chest and Lungs:Moderate inspiratory crackles right base
no wheezes
Heart:RRR, very distant heart sounds
S1, S2 OK
No murmur heard
Breasts:
Abdomen:Soft, nontender, nondistended, no organomegaly
hypoactive bowel sounds
Genitalia:
Extremities:Pulses equal and symmetric
Back and Spine:
Nervous System:pt. intubated
A+O x3, moves all extremities
Rectum:

Problem List
Problem DescriptionDate IdentifiedDate Resolved
1s/p inferolateral and RV MI20/07/1995
2V/Fib arrest requiring intubation20/07/1995
3Ventricular Ectopy (runs of VT)20/07/199521/07/1995
4Aspiration during emergency intubation20/07/1995

Progress Notes

20/07/1995

Summary to date:

Patient transferred from outside hospital to BI for PTCA for acute IMI/RVMI. In outside ER, pt experienced resp. distress; pulm. edema seen on CXR. Vomiting -> probable aspiration. V Fib arrest, defibrillated, intubated, stabilized and transferred to BIH. She had cardiac cath, and PTCA x2 with stent placements. Sent to the CCU intubated, for follow-up monitoring and care. On heparin drip, which was increased to 1300 u/hr at 12N because of subtherapeutic PTT.

Upon arrival in CCU she was intubated and sedated. HR 74, BP 120/65, RR 14. Problems include:

1. CAD, s/p PTCA with stents x2.
Plan: Continue IV NTG, heparin, ASA, Lopressor, and supplemental O2. Wean lidocaine drip. Replete K+, Ca++, Mg++ as needed. ECHO in 3-4 days to evaluate LV function.

2. Inf Dis.
WBC elevated to >20,000. CXR suspicious for infiltrate. Tracheal aspirate shows gm + cocci. Urine: WBC present.
Plan: Cover with antibiotics for gm + cocci and for anaerobes.

3. Renal: Patient has glucose and protein in the urine.
Plan: R/O diabetes, check glycosolated hemoglobin.

13:00:00 20/07/1995

Patient extubated without incident.

20:00:00 20/07/1995

 Temp spike to 38.7° C (101.6° F). Urinalysis, urine culture, blood cultures x2 done. Tylenol given. U/A revealed 23 WBC, culture pending. Started on Ampicillin 2 gm IV q 6 hrs.

00:01:00 21/07/1995

 PTT noted to be low at 53.4. Heparin bolus of 1000 u stat, and heparin drip increased to 1300 u/hr.

01:30:00 21/07/1995

 11 beat run VT, BP down 113/60 transiently. Pt denies CP and SOB. Patient asymptomatic. She continues IV NTG, which was increased to 50 mcg/min because BP higher in 130s, PAP=42-48/23-25.

04:00:00 21/07/1995

 Lidocaine d/c'd since ectopy was no longer evident. Heparin continues. IV fluids stopped at this time. Potassium checked and a bit low at 3.5. Given 40 mEq KCl stat. ABG earlier showed pO2=148, pCO2=53, pH=7.38 on 50% FiO2. FiO2 lowered to 40% cool neb. O2 sat was 98%.

15:00:00 21/07/1995

 Sheaths d/c'd after holding heparin - no complications. Remains hemodynamically stable, pt. feels well, denies CP. More alert today. CXR shows increased aeration bilaterally. NGT removed. Tolerating PO clear liquids, good bowel sounds. No further N+V. No BM yet. Pt. reported dysuria, and she remains on ampicillin. K=3.9. Getting PO and IV KCl. Hct down from 40 yesterday to 34.8 today.

19:00:00 21/07/1995

 Heparin restarted. 2000cc bolus, and drip restarted. Rt. groin site looks fine.

23:00:00 21/07/1995

 Doing well. Chest exam reveals Rt rales up halfway. Loose non-productive cough. O2 sat 98% on 4 L. Flow rate of O2 was dropped to 2L/min.

10:00:00 22/07/1995

 Continues to progress s/p IMI, good O2 sat, confortable. IV NTG weaned and started isordil. Continues on IV abx for pneumonia. Heparin maintained. Coumadin started yesterday. Continues with non-productive cough, rales 1/3 up on the right side. Plan to start cardiac rehab and dangling today.

12:01:00 22/07/1995

 Pt continues to do well. No CP, SOB, N/V, palpitations. Lung exam: late insp rales at right base, cleared with cough. Groin wound is dry, with no drainage or hematoma. Pulses OK.

She remains hemodynamically stable, and asymptomatic. Tracheal cultures show oral flora. Little evidence for pneumonia.

Urine culture not available yet, but GNR seen on smear. Will continue ampi.

14:00:00 22/07/1995

Patient transferred to the C-med floor from the CCU.

Medications

Ampicillin
Date and time QuantityUnitsRouteNotes
00:01:00 21/07/19952gmivq 6 hr
06:00:00 21/07/19952gmivq 6 hr
12:00:00 21/07/19952gmivq 6 hr
18:00:00 21/07/19952gmivq 6 hr
00:01:00 22/07/19952gmivq 6 hr
06:00:00 22/07/19952gmivq 6 hr
12:00:00 22/07/19952gmivq 6 hr

Ticlid
Date and time QuantityUnitsRouteNotes
12:00:00 21/07/1995250mgpobid
20:00:00 21/07/1995250mgpobid
08:00:00 22/07/1995250mgpobid

KCl
Date and time QuantityUnitsRouteNotes
18:00:00 20/07/199540meqivx1 over 2 hrs
04:00:00 21/07/199540meqiv
10:00:00 21/07/199540meqpo
13:00:00 21/07/199540meqpo

Lopressor
Date and time QuantityUnitsRouteNotes
20:00:00 20/07/199525mgpo
10:00:00 21/07/199550mgpo
22:00:00 21/07/199550mgpo
08:00:00 22/07/199550mgpo

ASA
Date and time QuantityUnitsRouteNotes
10:00:00 21/07/1995325mgpoqd
08:00:00 22/07/1995325mgpo

Isordil
Date and time QuantityUnitsRouteNotes
10:00:00 21/07/199510mgpo

Lasix
Date and time QuantityUnitsRouteNotes
18:00:00 20/07/199540mgivpx1

Coumadin
Date and time QuantityUnitsRouteNotes
22:00:00 21/07/199510mgpohs

Heparin
Date and time QuantityUnitsRouteNotes
02:00:00 22/07/19951000uivx1
09:30:00 22/07/19951000uivx1

Mevacor
Date and time QuantityUnitsRouteNotes
20:00:00 20/07/199520mgpoBID
10:00:00 21/07/199520mgpo
20:00:00 21/07/199520mgpo
08:00:00 22/07/199520mgpo

Colace
Date and time QuantityUnitsRouteNotes
10:00:00 21/07/1995100mgpobid
08:00:00 22/07/1995100mgpobid

Axid
Date and time QuantityUnitsRouteNotes
20:00:00 20/07/1995150mgpobid
10:00:00 21/07/1995150mgpobid
20:00:00 21/07/1995150mgpobid
08:00:00 22/07/1995150mgpobid

Continuous Medication Drips

 Heparin (25000 u in 250 cc)
Date and timeDrip rate (cc/hr)
11:00:00 20/07/199512
00:01:00 21/07/199513
12:00:00 21/07/19950
00:01:00 22/07/199513
08:00:00 22/07/199514
10:00:00 22/07/199515

Lidocaine (2 g in 250 cc)
Date and timeDrip rate (cc/hr)
11:00:00 20/07/19957.5
04:00:00 21/07/19950

Nitroglycerine (50 mg in 250 cc)
Date and timeDrip rate (cc/hr)
11:00:00 20/07/19959
16:00:00 20/07/19956
18:00:00 20/07/19959
04:00:00 21/07/199512
06:00:00 21/07/199515
10:00:00 21/07/19959
10:00:00 22/07/19950