CHIEF COMPLAINT: Bright red blood per rectum and shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 41-year-old female with past medical
history significant for gastric bypass surgery and possible hysterectomy.
She is currently intubated and sedated in the ICU, and history is per the
family but somewhat limited. The patient also is noted to have a prior
history of narcotic drug abuse, but per the family currently does not. The
family states that the patient for the past several days has been having
bright red blood per rectum for several episodes. Denies hematemesis or
coffee-ground emesis. They deny nausea and vomiting. She has been feeling
lethargic and weak and dizzy. There is possible syncopal episodes but very
unclear. The night before admission the patient was complaining of severe
shortness of breath. The patient was due to have an appointment today with
her hematologist for "anemia." However, the husband felt that the patient
looked ill and brought her to the emergency room. In the emergency room,
she was noted to be severely acidotic with acute renal failure and severely
anemic and therefore was intubated. Per the family, the patient denies
abdominal pain over the past week. They have noted that she is a little
bit lethargic and possibly confused over the past several days. Otherwise
the family does not seem to know too much in regards to any history
pertinent to the current episode for admission.
PAST MEDICAL HISTORY:
1. History of gastric bypass.
2. Anemia.
3. Possible hysterectomy.
4. Cholecystectomy.
5. Prior history of narcotic abuse, now not abusing narcotics per the
family.
MEDICATIONS:
1. Estrogen
2. Iron
ALLERGIES: NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Per the family significant for lupus.
SOCIAL HISTORY: Per the family. The patient does not smoke or drink.
However, the patient is currently intubated and I cannot confirm or deny
this.
REVIEW OF SYSTEMS: Is currently unobtainable due to the patient's
intubated and sedated status.
VITAL SIGNS: On admission, temperature 37.1 degrees, heart rate of 127,
blood pressure 110/52, respiratory rate of 28, saturating 97% on
assist-control ventilation at 100% FIO2.
EXAMINATION: GENERAL: The patient is a little bit agitated, but is
currently intubated and sedated.
HEENT: Normocephalic, atraumatic with an ET tube inside her mouth. The
sclerae are pale.
HEART: Tachycardic without murmurs.
LUNGS: Clear to auscultation bilaterally, anteriorly.
ABDOMEN: Is mildly firm with hypoactive bowel sounds. There are several
incisional scars from the patient's prior surgeries.
LOWER EXTREMITIES: Show no edema. Dorsalis pedis pulse 2+. Her nail beds
are pale.
LYMPHATIC: I do not appreciate any clavicular, cervical, axillary or
inguinal lymphadenopathy.
PSYCHIATRIC: I cannot assess at this time due to her intubated and sedated
state.
NEUROLOGIC: Cannot assess actually due to her intubated and sedated state.
MUSCULOSKELETAL: Cannot accurately assess due to her intubated and sedated
state.
SKIN: Appears warm, dry and intact.
LABORATORY VALUES: Of significance on admission, white blood cell count of
45.7, hemoglobin of 4.8, hematocrit of 16.2, MCV 72, platelets of 828.
Differential of 88% segs, 4% bands 5% lymphs. PT of 24.8, INR of 2.1,
glucose 135, BUN 27, creatinine 2.37, sodium 137, potassium 4.5, chloride
105. CO2 is less than 5. Anion gap is read as greater than 31, calcium
8.3, albumin 3.0, AST 85, ALT of 100, alk phos of 89, bilirubin 1.2. ABG
done in the emergency room after intubation shows pH of 7.060, PCO2 13.1,
pO2 of 485 on 100% FIO2 with settings of assist control, the rate of 16,
tidal volume 450, PEEP of 5. A venous lactic acid is 9.2.
IMAGING: Currently, the only available imaging is a chest x-ray
postintubation which shows a satisfactory ET tube as well as a right
central line placement placed satisfactorily. No EKG is shown in the
computer system.
ASSESSMENT/PLAN: A 41-year-old female here with severe anemia,
ventilator-dependent respiratory failure, severe leukocytosis and severe
acidosis.
1. Ventilator-dependent respiratory failure. The patient is currently
intubated and we will consult with pulmonology for further assessment.
I suspect she will require continued ventilation management due to her
severe acidosis. At this time it is unclear what is the cause of this
acidosis.
2. Severe anemia. She will be transfused with packed red blood cells. She
will be given FFP as necessary. There is a history of bright red blood
per rectum. A stat CT scan will be obtained of the abdomen and pelvis
to if there is any ischemic component causing dead bowel or something
similar. Gastroenterology has been consulted for possible scoping. At
this time it is unclear if this bleeding is upper or lower; therefore,
we will initiate Protonix and octreotide drips for the meantime.
3. Gastrointestinal bleeding. Unclear if this is upper or lower. We will
consult gastroenterology. Octreotide and Protonix drips. Again, we
will also check a CT scan to evaluate.
4. Severe anion gap acidosis. We will check methanol, ethanol levels as
well as salicylate levels. Critical care team has discussed with
nephrology and a dialysis line was be placed for likely emergent
dialysis. Drug screen will also be ordered. At this time it is unclear
the etiology.
5. Systemic inflammatory response syndrome syndrome. The patient meets
criteria upon admission for systemic inflammatory response syndrome with
elevated white blood cell count and tachycardia. At this time it is
unclear if she was infected, but we will check blood cultures as well as
a urinalysis and urine culture. No antibiotics currently as there is no
evidence of infection. Further medications and other therapies will be
done pending the CT scans and further evaluation.
6. Coagulopathy. Her INR is 2.1 for some unknown reason. We will give her
vitamin K as well as FFP as necessary to lower this.
7. Acute renal failure. The patient has elevated creatinine of unknown
etiology. Nephrology will be consulted likely for emergent dialysis.
We will check urine eosinophils. CT scan will evaluate for
hydronephrosis.
8. Transaminitis, unclear etiology. CT scan to image the liver. This may
be shock liver.
9. Prophylaxis. The patient will be on a Protonix drip for
gastrointestinal prophylaxis. Sequential compression devices and TED
hose for deep venous thrombosis prophylaxis. She anticoagulated
anyway.
CODE STATUS: The patient is full code.
Total time spent on this H & P is 70 minutes.
HOSPITALIST FOLLOW UP NOTE
S: intubated/sedated
underwent dialysis for acidosis
earlier blood was reported as positive, but now corrected as no growth
O:
Afebrile
80-90
130/50-60
20
95% on AC/450/16/60%/5
intubated/sedated
right neck central line
right femoral HD line
RRR
CTA anteriorly
Firm/hypoactive
no edema
fingers/toes a little mottled
hgb 11
BUN 10
Cr 0.72
anion gap 13
INR 2.1
low fibrinogen
normal FSP
abg 7.555/28/449
ethanol/methanol/ethylene glycol/salicylate negative
A/P:
41yo female
1. VDRF
2. SIRS, erroneous culture report, correct report is currently no growth to date
3. Severe anemia, resolved
4. Anion gap acidosis, resolved
5. Coagulopathy, ? DIC, but platelets wnl
6. Check CT abd/pelvis with contrast
7. sugars increasing, insulin gtt
8. broad spectrum abx
9. ECHO, TEE and TTE to eval for endocarditis
10. protonix gtt
additional 40 minutes of critical care time spent, following up studies, d/w consultants, updating family