MORBIDITY & MORTALITYCONFERENCE

LATA SHAH, MD

VA MEDICAL CENTER

ETSU

ADMISSION

• Admitted on 6/7/02• Complaints

– Worsening shortness of breath since recent d/c on 5/30/02

– Pedal edema x 1 week

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

SOCIAL HISTORY

• Former Heavy Smoker:– Smoked 2PPD for 45 years– Quit in 1990’s– Lives with wife

OUT PATIENT MEDICINES• CARDIAC MEDS

– 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

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

ADMISSION LABS

• CBC:WBC-19.1/Hb-12.2/Plt-227• BMP:141/4.2/103/29/22/1.6• ABG:7.42/43/64/92.4--- 30%• EKG:Paced rhythm @70/mn• CXR:Consistent with COPD and CHF

INITIAL ASSESSMENT/PLAN

• Severe COPD with possible exacerbation:• Exacerbation of CHF• CRF

INITIAL MANAGMENT

• Rule out MI • Breathing treatments • Induce diuresis carefully• Panculture• Start antibiotics for COPD exacerbation,

rocephine + zithromax

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.

HOSPITAL COURSE (2)

• ID consult- MRSA bacteremia Cultures: blood/ sputum / urine

• Cardiology consult- echo • General surgery consult- PEG tube

TEE - RESULTS

1. Reduced LV function (EF of 25%) with possible apical thrombus

2. No evidence of vegetations on the aortic, mitral or tricuspid valve

3. Pacer wires were fairly well visualized in the RA and RV with no clear evidence of vegetations.

4. Mild AI, mild TR, mild PI.

5. Anticoagulation with Coumadin and lovenox-60mg sc bid started (6/13/02)

HOSPITAL COURSE (3)

• Patient was started on theophylline for COPD• Patient was also started on Coumadin for

questionable organized LV thrombus

DISCHARGE PLAN

• No complaints • Vitals stable • Labs: INR 1.34 • Patient’s functional status did not improve

much• Coumadin education completed

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

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

PATIENT AT HOME 6/14 - 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

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

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

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.

READMISSION (4)As per admitting team: Assessment & Plan

1) 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

READMISSION (5)

2) Melena: UGI bleed with HIGH INR.

-FFP

-Aciphex

-H/H q8hrs.

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 - 7.43/35/49 at 36% FiO2 : on V-mask

with increased O2 to 8L and sats improved to +90%

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.

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

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

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)

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.