1. MORBIDITY & MORTALITY CONFERENCE
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 RESPIRATORY MEDS GI ANTIDEPRESSANS
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/ %
EKG:Paced
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/ /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 /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