1 / 21

Stephanie Piemontese PharmD Candidate 2010 University of Pittsburgh School of Pharmacy

Patient Case Presentation: “Right-sided flank pain, acute mental status changes and shortness of breath”. Stephanie Piemontese PharmD Candidate 2010 University of Pittsburgh School of Pharmacy. Chief Complaint.

elijah
Download Presentation

Stephanie Piemontese PharmD Candidate 2010 University of Pittsburgh School of Pharmacy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Patient Case Presentation:“Right-sided flank pain, acute mental status changes and shortness of breath” Stephanie Piemontese PharmD Candidate 2010 University of Pittsburgh School of Pharmacy

  2. Chief Complaint • Shortness of breath, mental status changes, and right-sided pain in abdomen and flank

  3. History of Present Illness • 59 yo female • Some right-sided pain off and on since she fell and broke her pelvis last March • worsened • IV fentanyl with some relief per EMS • Denies trauma to the area • Hx kidney stones • Obviously hyperventilating, difficulty breathing when came into ED • Could slow down rate when asked

  4. History of Present Illness (cont’d) • Abnormal speech • Not slurred • Problems with taking some medications • took 4 Zyprexa instead of 1 • Mix-up medications • Denies intentional ingestion of any substance out of the ordinary • Denies chest pain, nausea, sweats, radiation, or discomfort anywhere other than right flank

  5. Past Medical, Social and Family History • PMH: • Bipolar Disorder • HTN • Substance Abuse • Chronic Pain (? Osteoporosis/Fibromyalgia) • SH: • Quit smoking 1-5 years ago, denies EtOH/drug use • FH: • None specified

  6. Home Medication List and Allergies • Clonidine 0.1mg PO TID • Colace 100mg PO BID • Remeron 45mg PO HS • Zyprexa 20mg PO BID • Prilosec 20mg PO AC breakfast • Seroquel 600mg PO HS • Allergies: • fluoxetine (hallucinations) • ketorolac (migraine exacerbation) • prochlorperazine (migraine exacerbation) • butorphanol (migraine exacerbation) • sumatriptan (migraine exacerbation) • sulfamethoxazole-trimethoprim (thrush)

  7. Review of Systems • General: No fever/chills • Neurologic: No stroke/seizure • EENT: No sore throat • Cardiovascular: No chest pain/dysrhythmia • Respiratory: Clear breath sounds, hyperventilating • GI: Mild right lower quadrant abdominal pain, but more right flank pain • GU: No urgency/frequency/hematuria • Musculoskeletal: Chronic pain in right arm and hip from fall last March • Rest of review is negative

  8. Physical Exam • PE: Vitals: Temp 97.6°F HR 115-120 bpm RR 32bpm O2Sat 96-99% (room air)BP 112/51 mmHg • Weight 56.8kg • HEENT: normocephalic, no sign of trauma. • Eyes: EOMI. PEERLA. No nystagmus. • Oropharynx: normal • Neck: Supple • Chest: symmetrical • Lungs: clear • Heart: regular, tachycardic • Abdomen: soft

  9. Physical Exam (cont’d) • Extremities: no edema • Skin: free of rash • Back: no CVA pain • Neurologic: non-focal with normal cranial nerves • normal finger-to-nose coordination, downgoing great toes • equal grip strength • follows commands • Psychiatric: awake, alert, and oriented x3 • Speech is somewhat pressured and she mumbles, but it is not slurred. If you listen carefully enough she is quite intelligible.

  10. Labs • Included a BMP that showed normal electrolytes except for CO2 of 4. • BUN 28Cr 1.4 Glucose 90 Ca 10 WBC 14.9 H&H 13.6 &41.6 Plt 340 INR 1.2 • D-dimer0.31 • Troponin normal • Urine Tox screen positive for tricyclics • Blood Gas • pH 6.94 pCO2 11.5 pO2 236 HCO3 2.4 O2Sat 97% Anion Gap 24 • Head CT negative per radiology for any acute abnormalities • Abdominal CT and is negative for acute abnormalities other than a question of constipation • Sub acute fracture was noticed in the right symphysis pubis where she was fractured in the spring

  11. Toxicology • Acetaminophen – <0.2 ug/mL • Acetone - 27 (8 mg/dLacetoacetate) • Salicylate - 8mg/dL • Urine positive for TCAs • Ethanol - negative • Isopropyl - negative • Methanol - negative • Ethylene Glycol -negative • Urine – negative for • BZDs, cocaine, opiates, cannabis, phencyclidine

  12. Problem List • Acute • Metabolic acidosis • Compensating respiratory alkalosis • Acute Pancreatitis (lipase 2316 Units/L, amylase 901 IU/L) • Macrocytic anemia (MCV 113 fL) • PNA (MSSA, developed day 5) • Chronic • Bipolar Disorder • Chronic Pain Syndrome • HTN

  13. Metabolic acidosis • Sodium Bicarbonate drip • Intubated • Fomepizole • 800mg IV load, then 500mg q 12 hours • Resolved within 12 hours of admission

  14. Acute Pancreatitis • IV nutritional support • By discharge (day 12) lipase 848 Units/L and amylase was last noted at 101 IU/L

  15. Macrocytic Anemia • Hbg 13.6g/dL 8.9g/dL over admission • Cyancobalamin 1,000 mcg IM injection • Not found to have vitamin B12 deficiency or folic acid deficiency • Plan • Follow up with PCP

  16. MSSA Pneumonia • 5th day of admission noted possible left-sided effusion on Chest XR • Complaining of cough • Started on Unasyn 1.5g IV q 6 hours on day 6 • Sputum cultures from day 3 grew out MSSA • Therapy switched to PO Augmentin 875mg BID (total 10 days therapy)

  17. FAST-HUG(S) • Feed: • appropriate nutrition • Analgesia: • APAP 650mg q 4-6 hours • Sedation: • propofol 15mcg/kg/min , PRN lorazepam 1mg IV q 2h for anxiety • DVT/PE prophylaxis: • heparin 5,000 units SC q 12 hours • Head-above-bed elevation: • unknown • Stress Ulcer prophylaxis: • IV Pepcid 20 qd PrevacidSolutab 30mg NG qd  Prilosec 20mg ACbreakfast • Glucose Control: • Covered with sliding scale insulin • Skin: • Sween cream

  18. Bipolar Disorder • Continue • Zyprexa 20mg BID • Seroquel 200mg HS and 50mg q 1 a.m. and q afternoon • Remeron 45mg HS • Seek psychiatric evaluation and counseling • Supportive family

  19. Hypertension • Continue • Clonidine 0.1mg TID • Follow up with PCP • Consider alternative medications • diuretics, ACEIs, beta-blocker

  20. Chronic Pain • Evaluated for Fibromyalgia • Evaluated for Osteoporosis

  21. General Health • Counseled on medication management • Vaccines • Influenza • Pneumococcal (received inpatient) • Exercise – 30min/day, 3 days/week increase as tolerated • Evaluated for diabetes mellitus

More Related