Course in the ICU November 7, 2010 Subjective Awake No recurrence of seizure Difficult with onset of...

Course in the ICUNovember 7, 2010

Subjective• Awake• No recurrence of seizure• Difficult with onset of sleep• No other subjective

complaints

Objective• No neurologic deficits• 5/5 in all extremities• Clear lungs• Soft abdomen• Essentially normal physical

examination


• Assessment– Post stroke seizure, GTC type; – s/p CVD (?) infarct– Hypertension stage 2– Diabetes Mellitus Type 2

• Plan– Final schedule of MRI/MRA/MRV

• Orders– Esomeprazole 40mg/tab OD once diet is started

• Treatments– Head of Bed at 30-45 degrees– CBG Monitoring TID

• Referrals and Remarks– Minimize disturbance, refer if unable to sleep as claimed

04:15:00 AM 04:30:00 AM 04:45:00 AM 05:00:00 AM 05:15:00 AM 05:30:00 AM 05:45:00 AM 06:00:00 AM50

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210

November 07, 2010 Blood Pressure Monitoring

SystolicDiastolicHeart Rate

mm

Hg

MedicationsNovember 07, 2010

Generic Name Brand Name Dose Administration IndicationDipyrimadole Persantine 200 mg / tab BID Antiplatelet. Thromboxane and Phosphodiesterase inhibitorASA 80 mg / tab OD Antiplatelet. COX inhibitor

Phenytoin Dilantin 100 mg / cap TID Anticonvulsant, Antiarrhythmic. Sodium channel blocker.

Diazepam Valium 5 mg / vial PRNAnticonvulsant, anxioltic, benzodizepine. GABA-A receptor agonist

Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMN Imdur 60 mg / tab OD NitrovasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 Blocker

Insulin Glargine Lantus 45 Units OD, SQ Antidiabetic. Long-acting insulin analogueEsomeprazole Nexium 40 mg / IV OD Proton-pump inhibitorAtorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLKetorolac Kortezor 30 mg / vial PRN NSAID


Subjective• At the MRI suite

– Contrast media could not be administered at this point

– Creatinine is marginally elevated at 1.12 (cut-off is 1).

– Plan to hydrate the patient and get a repeat creatinine for contrast study

• No new complaints• Good appetite• No headache, dizziness,

nausea, vomiting

Objective• awake, coherent,

comfortable, follows commands, appropriate verbal output

• clear lungs, soft abdomen• moves all extremities• No bowel movement• CBG

– 5am 85mg/dL – 2pm 141 – 83– 4pm 256


• Assessment– Post-stroke seizure

• Plan– Hydrate the patient with PNSS 1L x 10 hours with

precautions– Monitor for signs of congestion– Start N-acetylcysteine 600mg/sachet in ½ glass of water OD– Diet: 1500 kcal/day (55:20:25) diabetic diet, low fat, 4g

sodium, high fiber diet in 3 meals and 2 snacks– Given Insulin glulisine (Apidra) 4 Units SQ for CBG 256


• Standing Orders– Acetylcysteine (Fluimucil) 600mg/sachet OD x 3

more doses (last dose 11/11, 8am)– Citicoline (Zynapse) 1gm/tab BID– Hold bisoprolol if HR < 55bpm

• Referrals and Remarks– VS q1, NVS q1

Cranial MRI

• Wedge-shaped Right inferior parietal cortical-subcortical encephalomalacia, gliosis and siderosis, presumably sequelae of a previous water-shed type infarction with hemorrhagic conversion

• Mild microvascular white matter ischemic changes on the left centrum semiovale

• Mild central cerebral volume loss

Lipid profile, Creatinine

• Cholesterol 3.75 (3.4 – 5.2)• HDL 2.33 (high)• LDL 1.39• Triglycerides 0.93• vLDL 0.42• FBG 4.87• Creatinine 0.76mg/dL (0.51 – 0.95)


Generic Name Brand Name Dose Administration Indication

Dipyrimadole Persantine 200 mg / tab BID Antiplatelet. Thromboxane and Phosphodiesterase inhibitorASA 80 mg / tab OD Antiplatelet. COX inhibitor

Phenytoin Dilantin 100 mg / cap TID Anticonvulsant, Antiarrhythmic. Sodium channel blocker.Diazepam Valium 5 mg / vial PRN Anticonvulsant, anxioltic, benzodizepine. GABA-A receptor agonist

Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMD Imdur 60 mg / tab OD NitrovasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 Blocker

Insulin Glargine Lantus 45 Units OD, SQ Antidiabetic. Long-acting insulin analogueInsulin Glulisine Apidra 4 Units OD Antidiabetic. Rapid-acting insulin analogue

Esomeprazole Nexium 40 mg / tab OD Proton-pump inhibitorAtorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLKetorolac Kortezor 30 mg / vial PRN NSAIDCiticoline Zynapse 1 g /tab BID Nootropic. PsychostimulantN-Acetylcysteine Fluimucil 600 mg / sachet OD Mucolytic. Nephroprotection from contrast


Subjective• Verbalized refusal to complete

contrast study of cranial MRI MRA MRV due to feelings of claustrophobia. Hyperventilated for a few minutes

• No recurrence of seizure in last 24 hours

• Asymptomatic, no headache, no dizziness

• Complained of dysuria ~3pm, ordered urinalysis for this.

Objective• Clear breath sounds, soft

nontender abdomen• No cyanosis, no edema• CBG uncontrolled since

patient resumed feeding from NPO post MRI MRA MRV


• Assessment– Post-gliotic seizure s/p CVD infarct RMCA, DM2– Impression: complicated UTI

• Plan– BP and glycemic control– Given Insulin glulisine (Apidra) 4 Units SQ for CBG of 274– Start sliding scale for Insulin glulisine

• 150 – 200, 2in SC• 201 – 250, 4in SC• 251 – 300, 6in SC

– Lactulose 30cc now IF still with no bowel movement– Discontinue esomeprazole– Schedule patient for EEG

Cranial MRA

• No aneurysm or any significant stenosis or vascular malformations seen

CV MRV

• No evident cortical vein or dural sinus thrombosis


• Standing Orders– Amoxicillin + Clavulanic Acid (Augmentin)

625mg/tab TID for 10 days• Referrals and Remarks– Apidra Sliding Scale– 180 – 220: 2– 221 – 250: 4– >250: inform MROD

Diagnostics

• EEG• Na, K, iCa, Mg, CBC• Urinalysis– Leukocytes = negative– WBC at 163/hpf– RBC at 4/hpf– EC at 0

Urine GS / CS

Urine GS• Leukocytes = negative• WBC – occasional • Gram (+) cocci in pairs –

rare• Gram (-) bacilli - occasional

Urine CS• Colony count: 20,000 CFU/mL urine• Organism: e. coli• Resistant to

– Ampicillin– Trimethoprim sulfamethoxazole– Levofloxacin

• Sensitive to– Cefazolin– Ceftazidime– Gentamycin– Amoxicillin clavulanic acid– Cefuroxime– Ceftriaxone– Nitrofurantoin



Dipyrimadole Persantine 200 mg / tab BID Antiplatelet. Thromboxane and Phosphodiesterase inhibitorASA 80 mg / tab OD Antiplatelet. COX inhibitor

Phenytoin Dilantin 100 mg / cap TID Anticonvulsant, Antiarrhythmic. Sodium channel blocker.Diazepam Valium 5 mg / vial PRN Anticonvulsant, anxioltic, benzodizepine. GABA-A receptor agonist

Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMD Imdur 60 mg / tab OD NitrovasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 Blocker

Insulin Glargine Lantus 45 Units OD, SQ Antidiabetic. Long-acting insulin analogueInsulin Glulisine Apidra 4 Units OD Antidiabetic. Rapid-acting insulin analogue

Esomeprazole Nexium 40 mg / tab OD Proton-pump inhibitorAtorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLKetorolac Kortezor 30 mg / vial PRN NSAIDCiticoline Zynapse 1 g /tab BID Nootropic. PsychostimulantN-Acetylcysteine Fluimucil 600 mg / sachet OD Mucolytic. Nephro-protection from contrastLactulose 30 ml Osmoticaly acting laxativeCo-Amoxiclav Amoclav 625 mg / tab TID x 10 days Antibiotic. Penicillin + Beta-lactamase inhibitor


Subjective• No recurrence of dysuria• AF last night, presently

sinus• Awake, noted to have

episodes of atrial fibrillation


abdomen, good urine output


• Assessment– Post gliotic seizure– Paroxysmal AF– HPN 2 DM 2

• Plan– For glycemic control and EEG today– Give 2 tablets of KCl (Kalium durule)– Hold Bisoprolol if HR < 55– For cardiac co-management for AF– Neuro

• Give Levetiracetam

– Please schedule 2D echo– For thyroid tests– Start Amlodipine, clonidine– Start Enoxaparin 60mg now then q12 SQ – Start Sitagliptin (Januvia)

• Standing Orders– Levetiracetam (Keppra) 500mg/tab BID – Amlodipine (Norvasc) 5m/tab BID– Bisoprolol (Concore) 10mg/tab OD AM, hold for HR<50bpm [revised from

11/7]– Bisoprolol (Concore) 5mg/tab OD AM, hold for HR<50bpm [revised from

11/7]– Clonidine 75mg/tab x 1 tab Sublingual PRN q4 for SBP >= 160mmHg– Sitagliptin (Januvia) 50mg OD before breakfast

• Referrals and Remarks– Medical Certificate– Keep overnight at ACSU to observe rhythm– Possible TROC at 11/11 if no recurrence of arrhythmia– Enoxaparin 60mg now then q12 if ok with Dr. Orteza

Thyroid Function tests

• TSH 3.01 uIU/mL• FT3 2 pg/mL• FT4 0.83 ng.dL



Dipyrimadole Persantine 200 mg / tab BID Antiplatelet. Thromboxane and Phosphodiesterase inhibitorASA 80 mg / tab OD Antiplatelet. COX inhibitorEnoxaparin Clexane 60 mg BID Anticoagulant. Low molecular weight heparin. Factor Xa inhibitor

Phenytoin Dilantin 100 mg / cap TID Anticonvulsant, Antiarrhythmic. Sodium channel blocker.Diazepam Valium 5 mg / vial PRN Anticonvulsant, anxiolytic, benzodiazepine. GABA-A receptor agonistLevetiracetam Keppra 500 mg / tab BID Anticonvulsant

Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMD Imdur 60 mg / tab OD Nitro-vasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 BlockerAmlodipine Norvasc 5 mg / tab BID Selective Calcium channel blockerClonidine Catapres 75 mg / tab PRN Sympatholytic antihypertensive. Centrally acting alpha2 agonist.



Insulin Glargine Lantus 45 Units OD, SQ Antidiabetic. Long-acting insulin analogueInsulin Glulisine Apidra 4 Units OD Antidiabetic. Rapid-acting insulin analogueSitagliptin Januvia 50 mg OD Antidiabetic. Secretagogue, DPP-4 inhibitorD50 50 1/2 vial PRN Hypertonic carbohydrate solution. Dextrose 50%

Atorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLKetorolac Kortezor 30 mg / vial PRN NSAIDCiticoline Zynapse 1 g /tab BID Nootropic. PsychostimulantN-Acetylcysteine Fluimucil 600 mg / sachet OD Mucolytic. Nephro-protection from contrastLactulose 30 ml Osmotically acting laxativeCo-Amoxiclav Amoclav 625 mg / tab TID x 10 days Antibiotic. Penicillin + Beta-lactamase inhibitorPotassium Chloride Kalium Durule Potassium supplement


Subjective• No recurrence of AF in

cardiac monitor• Presently asymptomatic,

awake

Objective• No murmurs, regular

rhythm. Clear BS, soft nontender abdomen. No cyanosis, no edema. Full and equal pulses

04:00:00 PM 08:00:00 PM507090

110130150170190210230



mm

Hg


• Assessment– Post gliotic seizure– Paroxysmal AF– HPN 2 DM2

• Plan– Okay to start enoxaparin– Give D50-50 ½ vial for CBG <= 70. Relay all CBG prior to giving Insulin– Revise Apidra sliding scale. Give only before meals

• 180 – 220 2 units• 221 – 250 4 units• >250 inform MROD

– Decrease Bisoprolol to 10mg OD– Discontinue amlodipine– Start diltiazem 30mg/tab TID

• Hold for SBP < 110 mmHg OR HR < 50bpm

– Start dabigatran (Pradaxa) 110mg/tab BID– Discontinue Enoxaparin (Clexane) once dabigatran started– Keep in low dose ASA (80mg OD) for coronary prophylaxis even if on Pradaxa– Continue current doses of phenytoin and levetiracetam



Dipyridamole Persantine 200 mg / tab BID Antiplatelet. Thromboxane and Phosphodiesterase inhibitorASA 80 mg / tab OD Antiplatelet. COX inhibitorDabigatran Pradaxa 110 mg / tab BID Anticoagulant. Direct thrombin II inhibitor

Phenytoin Dilantin 100 mg / cap TID Anticonvulsant, Antiarrhythmic. Sodium channel blocker.Diazepam Valium 5 mg / vial PRN Anticonvulsant, anxiolytic, benzodiazepine. GABA-A receptor agonistLevetiracetam Keppra 500 mg / tab BID Anticonvulsant

Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMD Imdur 60 mg / tab OD Nitro-vasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 BlockerClonidine Catapres 75 mg / tab PRN Sympatholytic antihypertensive. Centrally acting alpha2 agonist.

Diltiazem Dilzem 30 mg / tab TID Antiarrhythmic. Calcium Channel blocker



Insulin Glargine Lantus 45 Units OD, SQ Antidiabetic. Long-acting insulin analogueInsulin Glulisine Apidra 4 Units OD Antidiabetic. Rapid-acting insulin analogueSitagliptin Januvia 50 mg OD Antidiabetic. Secretagogue, DPP-4 inhibitorD50 50 1/2 vial PRN Hypertonic carbohydrate solution. Dextrose 50%

Atorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLKetorolac Kortezor 30 mg / vial PRN NSAIDCiticoline Zynapse 1 g /tab BID Nootropic. PsychostimulantN-Acetylcysteine Fluimucil 600 mg / sachet OD Mucolytic. Nephroprotection from contrastLactulose 30 ml Osmotically acting laxativeCo-Amoxiclav Amoclav 625 mg / tab TID x 10 days Antibiotic. Penicillin + Beta-lactamase inhibitorPotassium Chloride Kalium Durule Potassium supplement


Subjective• No recurrence of seizure-

like episodes• No slurring of speech• No chest pains or

palpitations• Able to walk around the

room


abdomen, no cyanosis or edema

12:00:00 AM 04:00:00 AM 08:00:00 AM 12:00:00 PM 04:00:00 PM 08:00:00 PM50

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mm

Hg


• Assessment– Paroxysmal AF– Post-gliotic seizure– HPN2 DM2

• Plan– Continue anticoagulants– Decrease diltiazem to 30mg BID. Hold for SBP < 110 or

HR <50– For 24 hour halter monitoring after 1 week– Follow up after 2 weeks

Take Home Medications


Dipyridamole Persantine 200 mg / tab BID Antiplatelet. Thromboxane and Phosphodiesterase inhibitorASA 80 mg / tab OD Antiplatelet. COX inhibitorDabigatran Pradaxa 110 mg / tab BID Anticoagulant. Direct thrombin II inhibitor

Perindopril Conversyl 8 mg / tab OD Long-acting ACE inhibitorISMD Imdur 60 mg / tab OD Nitro-vasodilatorBisoprolol Concore 10 mg / tab OD Selective Beta1 Blocker

Insulin Glargine Lantus 42 Units OD, SQ Antidiabetic. Long-acting insulin analogue

Sitagliptin Januvia 50 mgOD,

pre-breakfast Antidiabetic. Secretagogue, DPP-4 inhibitor

Diltiazem Dilzem 30 mg / tab TID Antiarrhythmic. Calcium Channel blocker

Atorvastatin Lipitor 20 mg / tab OD Statin. HMG-CoA reductase, LDLCo-Amoxiclav Amoclav 625 mg / tab TID till 11/19 Antibiotic. Penicillin + Beta-lactamase inhibitor


Subjective• No subjective complaints

Objective• Clear breath sounds, normal

rate regular rhythm

12:00:00 AM 04:00:00 AM507090

110130150170190210230



mm

Hg


• Assessment– Paroxysmal AF

• Plan– Discharge– Schedule for halter monitoring in an OPD basis

Course in the ICU November 7, 2010 Subjective Awake No recurrence of seizure Difficult with onset of...

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