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Course in the ICU November 7, 2010

Course in the ICU November 7, 2010. Subjective. Objective. No neurologic deficits 5/5 in all extremities Clear lungs Soft abdomen Essentially normal physical examination. Awake No recurrence of seizure Difficult with onset of sleep No other subjective complaints.

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Course in the ICU November 7, 2010

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  1. Course in the ICUNovember 7, 2010 Subjective Objective No neurologic deficits 5/5 in all extremities Clear lungs Soft abdomen Essentially normal physical examination • Awake • No recurrence of seizure • Difficult with onset of sleep • No other subjective complaints

  2. Course in the ICUNovember 7, 2010 • 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

  3. MedicationsNovember 07, 2010

  4. Course in the ICUNovember 8, 2010 Subjective 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 • 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

  5. Course in the ICUNovember 8, 2010 • 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

  6. Course in the ICUNovember 8, 2010 • 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

  7. 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

  8. 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)

  9. MedicationsNovember 08, 2010

  10. Course in the ICUNovember 9, 2010 Subjective Objective Clear breath sounds, soft nontender abdomen No cyanosis, no edema CBG uncontrolled since patient resumed feeding from NPO post MRI MRA MRV • 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.

  11. Course in the ICUNovember 9, 2010 • 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

  12. Cranial MRA • No aneurysm or any significant stenosis or vascular malformations seen

  13. CV MRV • No evident cortical vein or dural sinus thrombosis

  14. Course in the ICUNovember 9, 2010 • 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

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

  16. Urine GS / CS Urine GS 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 • Leukocytes = negative • WBC – occasional • Gram (+) cocci in pairs – rare • Gram (-) bacilli - occasional

  17. MedicationsNovember 09, 2010

  18. Course in the ICUNovember 10, 2010 Subjective Objective Clear breath sounds, soft abdomen, good urine output • No recurrence of dysuria • AF last night, presently sinus • Awake, noted to have episodes of atrial fibrillation

  19. Course in the ICUNovember 10, 2010 • 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)

  20. 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

  21. Thyroid Function tests • TSH 3.01 uIU/mL • FT3 2 pg/mL • FT4 0.83 ng.dL

  22. MedicationsNovember 10, 2010

  23. MedicationsNovember 10, 2010

  24. Course in the ICUNovember 11, 2010 Subjective Objective No murmurs, regular rhythm. Clear BS, soft nontender abdomen. No cyanosis, no edema. Full and equal pulses • No recurrence of AF in cardiac monitor • Presently asymptomatic, awake

  25. Course in the ICUNovember 11, 2010 • 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

  26. MedicationsNovember 11, 2010

  27. MedicationsNovember 11, 2010

  28. Course in the ICUNovember 12, 2010 Subjective Objective Clear breath sounds, soft abdomen, no cyanosis or edema • No recurrence of seizure-like episodes • No slurring of speech • No chest pains or palpitations • Able to walk around the room

  29. Course in the ICUNovember 12, 2010 • 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

  30. Take Home Medications

  31. Course in the ICUNovember 13, 2010 Subjective Objective Clear breath sounds, normal rate regular rhythm • No subjective complaints

  32. Course in the ICUNovember 13, 2010 • Assessment • Paroxysmal AF • Plan • Discharge • Schedule for halter monitoring in an OPD basis

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