Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

9/13/12 HUH IM M&M

No description
by

Patrick Woodard

on 10 April 2014

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of 9/13/12 HUH IM M&M

11:00 am
MICU Intern Acceptance Note
7/21/12 17:00
Physical Exam - A&Ox3, ND
CTAB, no rales/rhonchi/wheezes
RRR normal S1, S2
S/NT/ND/NABS
2+ pulses
GCS 15
A/P - similar to FP resident transfer note.
6:03 am
23:53 pm
3:56 am
22:21 pm
12:15 pm
22:24 pm
1:33 am
3:54 am
Patient transferred to MICU
16:30 pm
Arrival at HUH ER
Transferred to WHC
17:20 pm
138
4.3
105
24
94
6
0.6
9.7
Mg
P0
4
/ / / / /
0.5 16 16 72 4.0
Amylase
Lipase
36
26
10.2
13.9
40.6
275
6:05 am
138
4.0
107
24
80
3
0.7
8.8
Mg
P0
4
10.2
13.2
38.5
265
7:11 am
136
3.9
107
23
113
5
1.0
8.1
Mg
P0
4
13.4
13.6
39.2
184
7:00 am
139
3.6
113
22
138
23
2.4
7.9
Mg
P0
4
/ / / / /
2.0
39 18 51
4.5 2.7
18.4
11.9
33.3
67
9:05 am
141
3.8
116
20
146
40
5.1
7.9
Mg
P0
4
/ / / / /
1.5

74
44 46
4.3 2.5
2.5 1.6
22.1
10.6
29.8
55
18:55 pm
138
3.3
114
18
140
44
5.9
7.4
/ / / / /
1.1
76 60
42
3.8 2.2
20.8
9.2
25.9
45
2:18 am
138
3.3
113
45
120
45
6.2
7.4
Mg
P0
4
/ / / / /
1.0
75 67
42
3.7 2.2
CPK
164
20.4
8.9
25.5
43
20:28 pm
139
3.0
114
18
130
47
7.5
6.9
/ / / / /
1.0
54 63
40
4.0 2.1
LDH
CPK CKMB Tn Mg
1513
142 0.8 0.01
74
14.3
7.6
21.6
44
3:00 am
143
2.8
113
20
124
43
7.0
7.1
Mg
P0
4
/ / / / /
1.2 41 40 40
4.0 2.2
13.7
7.0
19.4
50
15:00 pm
144
3.2
114
23
112
47
7.5
8.1
10.2
13.9
40.6
275
2:30 am
142
3.2
111
25
113
36
6.1
7.4
Mg
P0
4
/ / / / /
1.6
44 31 37
3.8 2.2
LDH
1182
2.7
1.7
10.2
13.9
40.6
275
6:50 am
139
3.9
108
25
87
4
0.6
8.6
Mg
P0
4
/ / / / /
Amylase
Lipase
36
26
8.6
12.4
35.8
233
3.9
2.0
138
4.3
105
24
94
6
0.6
9.7
Mg
P0
4
4.2 2.0
4.0 2.0
2.8
1.8
3.1
1.8
C3 C4 Hapto
64 11 3
3.1
1.6
LDH
1513
Retic # Retic %
3.20 0.0793
UTox UNa UK UCl UCr UPro
Neg 91 38 105 118 1127
16.0
29.5
1.3
18.0
1.5
29.2
Fibrin
320
D-dimer
10.4
18.7
1.6
30.2
15.6
1.3
2.75
HIV
NR
Neg
ANA CH50
30
15:30 pm
No growth
Stool Cx
Nares
Urine Cx
Stool O&P
Blood Cx
Blood Cx
No growth
No growth
No growth
No growth
None seen
C. diff
Neg x 2
ER Physician H&P
7/15/12 20:15

CC: Abd pain x 4 days

HPI: Moderate, Sharp "pain" in RLQ
+ N/D, worsened by food, relieved by nothing

ROS: Nausea, diarrhea

PMHx: None

PSHx: cholecystectomy

Meds: flagyl

V 105/71 78 18 98.9 98% RA
Abd: Soft, tender in RLQ, no guarding or rebound, rectal deferred
Physical exam otherwise normal

Impression:
Abd pain r/o appendicitis; gastroenteritis
Surgery consult
25 yo female with abd pain likely gyn etiology, less likely intraabdominal changes. Likely self-limited. No acute abdomen.

Assessment/Plan
No acute surg. intervention
F/u gyn consult
If symptoms worsen or persist, may see Dr. Ford as outpatient
Nursing Note
Admission: Abd pain with rectal bleeding

22:30 Pain decreased to 2/10, waxing/waning

23:30 C/o CP, CE ordered

00:30 Transferred to 3N
ER Physician Progress Note
Gyn & surgery called

Gyn saw patient at 20:45

Surgery saw pt at 22:48
OB/GYN Consult
Impression:
Likely acute GI issue
L ovarian cyst - likely hemorrhagic, no acute issue

Plan:
Continue GI workup
F/u outpt gyn prn
Night Hawk Read
CT Abdomen/Pelvis Without Contrast
Received at HUH 7/15/12 23:01:41

Partially calcified lymph nodes in mediastinum and L hilum. 8mm LLL nodule. Cluster of small nodules in RLL. No effusions.

Prior cholecystectomy. The liver, pancreas, adrenal glands, and spleen are grossly unremarkable.

No renal or urinary calculi.

Moderate stool in the colon.

*Diffuse mucosal thickening and surrounding edema-involving the ascending colon extending into the proximal transverse colon, likely representing colitis. No evidence for abscess, small bowel obstruction, free fluid, or free air.

Appendix not seen with certainty.

Mildly enlarged RLQ mesenteric lymph nodes, likely reactive.
Night Hawk Read
Transvaginal Ultrasound
Received at HUH 7/16/12 08:16:26

Endometrial stripe within the normal limits

Intact blood flow to ovaries, no torsion

Complex L ovarian cyst measuring 2.1cm

Subcentimeter follicles R ovary

Mild free fluid noted adjacent to L adnexa
H&P
07/16/12 14:00
CC: abd pain x 3 days

HPI: 25 yo previously healthy female s/p cholecystectomy who presented with abd pain, D/N x 3 days. Abd pain 10/10, nonradiating umbilical and RLQ, sharp and pressure-like, relieved by dilaudid given in ER, exacerbated by cough and certain positions. Waxing and waning. Pt went to urgent care for abd pain and received Flagyl, last dose taken 7/15/12 at 1400pm. Diarrhea is loose, watery stools without blood, 8 episodes in one day, then 2 episodes x 1 day, then 1 episode on 7/15/12. + nausea with pain, but no vomiting. Pain currently 0/10. Denies recent travel or new food.

Documented ER course.

ROS: N/D. Denies constipation, F/C, HA, ENT pathology, vomiting, numbness/tingling in limbs.
Allergies: Erythromycin PMHx: None
PSHx: Cholecystectomy 2008, R wrist and R ankle OR/IF 2011

Meds: OCP "irregular"
FHx: MGF: cancer, Mother: HTN, MGM: MI vs CVA
SHx:
Tob: 1/2 ppd x 7 years
EtOH: once per week, 2-3 drinks, liquor
No drug use
Sexual activity, sometimes uses protection, last HIV NR 2011
Lives with b-in-law and sister
- NPO except meds and D5 1/2 NS @ 125cc/hr
- Protonix 40mg IV q12 for ?gastritis/GERD
- Will consult GI if pain persists
- Phenergan 12.5mg IV q4 prn N/V
- CBC, BMP, Mg, Phos, UA, urine HCG, HIV elisa

2. Diarrhea, improving
- Pt on flagyl at home and given dose in ER
- Will not continue, c-diff is unlikely etiology
- Stool studies: WBC, culture, O&P, FOBTx2

3. L ovarian cyst, likely hemorrhagic
- Seen by GYN and no acute intervention
- F/U as outpt

4. GI & DVT ppx - protonix 40mg IV q12 and B thigh-high TEDs.

5. Dispo - obvs. Will D/C home once clinically improved.

6. Obesity - will counsel pt about diet modification

7. Tobacco abuse - will offer pt. nicotine patch

Attending Note: Pt admitted acute _________ syndrome. Will follow with Fam Med Team
Physical Exam
106/50 97.8 20 99% RA 56 5'0" 160.5Lbs BMI 31
General: NAD
HEENT: PERRL no nasal secretions, no oropharyngeal injection, gross hearing intact
Neck: No thyromegaly
Pulm: Good aeration, CTAB, No W/R/R
CV: RRR S1&S2 +, No m/r/g
Abd: BS+/S/ND, umbilicus & RLQ ttp, no hepatosplenomegaly, DRE performed in ER, see surgery consult
GU: Gyn performed in ER, see surgery consult
Lymph: No LAD
Extremities: 2+ pedal pulses, no c/c/e, Strength 5/5 throughout
Skin: No rashes
Neuro: GCS 15/15, A&Ox3

Labs, radiology, and consults documented.

Assessment/Diagnoses:
25 yo previously healthy female s/p cholecystectomy with abd pain
1. Abd pain, etiology unclear - RLQ, likely colitis, inflammatory vs. infectious
- not acute abd per surgery, will reconsult if pain persists
- no gyn acute concerns per gyn
- cont. to monitor closely
- Dilaudid 0.5mg IV q6 prn pain
Family Medicine Intern Note
7/17/12 09:45

24 hr: feels much better, but "maybe because of pain meds"
Vitals: 97.7 61 18 96/52
Abd: S/NT/bowel sounds present
Labs section left blank
Assessment: Acute colitis (cause unknown)
Plan:
Bowel rest — start clears today
Follow up on studies
Family Medicine Intern Progress Note
7/18/12 14:30
24 hr: abd pain came back and she feels nauseated.
Vitals: 98.4 72 16 94/58
Abd: +RLQ pain, BS+
No labs documented
Assessment:
Breakthrough RLQ abd pain
Plan:
Continue Dilaudid
Add Percocet 5/325 PO q4 prn
Family Medicine Intern Progress Note
7/18/12 (no time)
Asked by charge nurse to meet with patient's sister about temp of 99 because family baseline is 97.2, explained that temperature is nothing to worry about at this current temperature. Pt also demanding pain medications. Pharmacy only dispense Cipro 400mh IV q12 and not 500mg IV q12.
Plan:
pt/sister reassured
for pain meds as scheduled
order Cipro 400mg IV q12, first dose now
Family Medicine Intern Progress Note
7/19/12 10:45 am
24 hr: pt says she has thrown up 5x. Vomitus consists mainly of yellow fluid. She had one episode of diarrhea yesterday 7/18 with frank blood in stool.
Vitals: 99.0 90 18 105/58
Exam [sic]
An anxious lady
Abdominal exam shows RLQ tenderness

Assessment
Acute colitis (of unknown etiology)
Consult GI
Plan:
F/u Stool studies
Continue pain meds
F/u on GI consult
Keep NPO
D5 1/2 NS at 125 cc/hr
Family Medicine On-Call Note
7/19/12 23:30
Asked to review patient by charge nurse. Patient complains of nausea despite being on Zofran 4mg. Reported she was unable to complete GoLytely for bowel prep because of feeling sick. Pt. adamant not to proceed with GoLytely. Will be NPO from midnight.

Plan
For GI team to decide to scope or not despite patient ________ to drink GoLytely.
Family Medicine On-Call Note
7/20/12 0500
Asked to review patient again for the third time. Informed the staff nurse that she passed some blood in her fecal matter and requested a doctor to observe. Slightly stained toilet bowel without fecal matter observed so it is extremely difficulty for me to certify that patient's bleed/rectal or vaginal although she claims she is not menstruating.

Vitals 102/52 85 98.9 16

Plan
Requested for stool sample
Counsel patient
GI Follow-up
7/20/12 0830
24 hr — increased abd pain, vomiting with GoLytely, had bloody bowel movement
Vitals BP 100/52 RR 17 HR 90 Tc 99.1
Pertinent Physical
(abridged)
RUQ tenderness, now improved
No rebound, guarding. NABS
CNS A&Ox3

Labs documented with notation on Cr, WBC, Hb.

Assessment
Acute vs. acute on chronic inflammatory process
Patient's abd pain has increased
WBC count trending up. Afebrile.
Please panculture patient
Patient unable to drink GoLytely
Will do EGD/Colonoscopy when stable
Plan
Keep NPO
Abd x-ray stat
Hydrate well
no colonoscopy at this time
IV abx after pancx — leukocytosis r/o sepsis
GI Fellow Follow-up Note
7/20/12 0930

Patient not adequately prepped for colonoscopy.

Plan
no scope at this time
hydrate patient
abd flat plate
Panculture
Continue IV abx
continue NPO
Family Medicine PGY-2 Note
7/20/12 1055
RN staff approached team with pt's concerns that she was not informed about her treatment plan. Patient was concerned about not getting better and feeling weak. She was unable to complete the colonoscopy prep due to N/V. Colonoscopy was canceled today due to poor prep. Pts sister requests that enemas be given for bowel prep so that the colonoscopy can be performed today. It was explained in detail that multiple enemas are not ideal, unsafe, and do not provide adequate bowel prep. Both pt. and sister are anxious baout her current condition. Contact isolation was exaplained about testing for a c-diff toxin. It was also explained that c-diff was not initially thought to be the likely etiology for the pt's presenting abd pain. Pt. also c/o bruising from lab draw and that the nursing staff is slow to respond to her call button. Attending was present and states that he will inform

the GI attending of her concerns and to see if the GI team could see her and address the sister at this time.
Family Medicine Intern Progress Note
7/20/12 1200
24 hr - patient could not drink GI prep

Physical Exam [sic]
Tc 99.9 HR 90 RR 17 BP 100/52
A young woman that appears really anxious
RLQ abd pain on physical exam

Labs documented with notation of decline in platelets, increase in WBC, Cr.

Assessment
Acute colitis (etiology unknown)
Plan
WBC going up so panculture
CXR stat
AXR stat
F/u with GI
D5 1/2 NS at 125cc/hr
Family Medicine Intern Progress Note
7/20/12 1500
Dr. ______ and I were called to see patient's mom. Pt's mom was aware that patient did not get EGD and colonoscopy because she could not tolerate the prep. Mom also wanted to know why pt was on contact isolation. Both situations were explained explicitly. Patient at this time states that she has no abd pain but is very nauseous. Mom and pt clearly understood our explanations. Our plan is to follow up with GI consult and recommendations.
GI Fellow Follow-Up
7/21/12 11:15
24 hr — N/V + bilious. Pt continues to have BRBPR and melena. Panic attack with intermittent confusion ? delirium.
Physical Exam
BP 135/70 HR 105 RR 20 Tc 99.5 Tmax 99.8
HEENT: severe dehydration
Pulm: CTAB
Abdomen: Soft, diffuse tenderness in RLQ and LLQ. No guarding/rigidity. Hypoactive bowel sounds.
CNS: extremely anxious, A&Ox3, no focal findings

Labs documented and circled:
Cl, HCO3, BUN, Cr, Glc, WBC, Hb/Hct, Plt, N%, Mg, Tbili, AST, Tprot, Alb
A/P
R/o sepsis — pancx and broaden abx coverage, MICU consult and ID consult
Severe dehydration — patient needs to be aggressively hydrated. Strict IOs
ARI r/o ATN 2/2 #2 — renal consult, u/s, urine lytes
R/O DIC — DIC panel
R/O HIT — HIT antibodies
GI bleed with anemia - continue NPO, IV Protonix, monitor H&H q8, transfuse as needed to 10/30
Electrolyte abn with metabolic acidosis — fix Mg and K
Colitis with disseminated inf — f/u cultures, stool studies and c.diff toxin — r/o toxic megacolon
ID consult
7/21/12 11:45
Blurred vision, auditory and visual hallucinations noted.
History unobtainable due to confusion and AMS
Physical Exam
Vitals Tc 99.5 Tmax 99.8 BP 130/70 RR 20 HR 105
Very agitated, confused, AMS, visual and auditory hallucinations, tremulous saying "I'm going to die." MM pink and dry, lips dry. No skin rash. Negative kernig and brudniski, no neck stiffness. Blurred vision.
Abdomen documented as normal

Assessment
SIRS
ARF
Acute gastroenteritis
thrombocytopenia
Anxiety/delirium, possible encephalitis

Recommendations
Consider HUS in presence of above
Stool studies, panculture
LP if no contraindication, for bactera, protozoa, cell count, chemistry
Start ampicillin to cover listeria, d/c cipro
Peripheral smear for schistocytes
Consider MICU transfer
Discussed with primary team and mother.
RRT Note
7/21/12 11:54
Vitals HR 132 RR 22 SpO2 96% on RA BP 85/44
Reason for RRT: drop in BP, change in mental status
Preliminary diagnosis: Hemolytic uremic syndrome

HPI notes change in WBC, renal function, mental status, Plt count, hallucinations. RRT called because patient started shaking and then became rigid with eyes rolled upward and foaming _______.

Physical Exam
General: Young female, very agitated and disoriented
HEENT: Pink _____, dry buccal mucosa
Pulm: CTAB
CV: No JVD, S1S2, tachy, no M/R/G
Abd: S/NT/no OM
Ext: No edema 2+ pulses B
CNS: conscious, agitated, not allowing nurses to touch her, screaming, oriented to place. Moving all extremities
Assessment/Plan
1. Seizure Episode
patient received Ativan 2mg IV once, continue ativan on prn basis
consider EEG if repeated episode
2. Hypotensive 2/2 dehydration, sepsis
will bolus patient with IVF, monitor I/Os.
Patient tachy, increased WBC, hypotensive-> sepsis with source being GI tract 2/2 AGE
F/u ID recs, repeat BCx
3. ? TTP vs HUS
Patient has AGE, thrombocytopenia, AMS, ARF, anemia
Aggressive hydration
Get stool for O&P culture, shiga toxin, c. difficile, peripheral smear
Consider hematology and renal consult
Transfer to MICU
RRT Note
7/21/12 13:45
Hematology fellow contacted. Recommended DIC workup, CBC, CMP, and contact him again once results available.
Family Medicine Resident Transfer Note
7/21/12 12:43
A/P:
1. SIRS with acute colitis vs. gastroenteritis
F/u pancultures
transfer to MICU
Stool studies
2. Possible HUS
thrombocytopenia 233->55, AKI, neurologic changes, Hb 13.6->10.6
Pt producing urine but dark
give 1L bolus NS, then D5NS at 150cc/hr
Continue aggressive IVF hydration
Urine electrolytes
F/u renal
3. ? anxiety d/o with psychosis
pt has h/o anxiety disorder/depression x 2 months, now with hallucinations
correct electrolyte abnormalities
evaluate for HUS
psych consulted, please follow-up
continue Xanax
Family Medicine Intern Note
7/21/12 18:20
Physical Exam [sic]
A young woman very anxious, mildly trembling, no other patient physical findings
Labs noted
Assessment
Acute gastritis of unknown etiology
Plan
F/u patient at CCU
MICU resident note
7/21/12
Hematology was contacted after fibrinogen, d-dimer, coags, repeat BMP, CBC, LDH, total bilirubin levels came back. Fellow was informed about all the lab results. He expressed his impression favoring DIC and suggested for FFP transfusion and repeat DIC and coag study tomorrow AM.

Possibility of HUS (TTP) and subsequent plasmapheresis was discussed. However, given patient's earlier hypotensive state, he expressed his preference to transfuse FFP and if patient remains stable for at least 12 hours, plasmaphoresis may be done tomorrow. Quenton catheter placement request was done to gen surg for possible plasmaphoresis tomorrow.
Renal progress note
7/22/12 0700

24 hr - possible plasmaphoresis

Physical Exam (pertinent)
Mild diffuse tenderness in abd
Alert, oriented, awake.
Trace edema, 2+ pulses

Attending:
Nonoliguric acute renal failure with hemolytic anemia, 10 gm proteinuria --> HUS vs. TTP
Suggest Quinton for plasmaphoresis as per hematology
GI Follow-up
7/22/12 11:00

Assessment
HUS
Seizure/anxiety disorder
Plan
Continue NPO
IV abx
F/u ID recs
Continue IVF
F/u CT head
No endoscopy at this time
ID follow up
7/22/12 0700
24 hr - no diarrhea, vomitted x 1, transferred to MICU
Unable to examine patient as she was sleeping and mother did not allow it

Attending
Recommendations
Monitor CBC closely
Adjust dose of ampicillin to 2gm IV q12
Hematology consult for evaluation of possible HUS and plasmaphoresis
Renal f/u noted.
Fluids and transfusion per ICU team
Discussed the case with mother extensively, explained current situation and plan as mentioned in this note. She appears satisfied with management and did not voice any concerns.
MICU Intern Progress Note
7/22/12 13:30
24 hr - NAE o/n. Seen by heme, ID, renal, GI

Physical Exam (pertinent)
BP 102/55 HR 51-89 Tc 98.1 Tm 98.3 RR 29
General NAD A&Ox3
No abnormal physical exam findings
I/Os +4450/-532 +3913 UOP 26-100

Assessment and plan
SIRS r/o sepsis acute colitis vs. gastroenteritis - Pt gives h/o swimming in a dirty lake, possibility of listeria infection. Will continue Ampicillin, f/u stool studies
Possible HUS - hematology says likely TTP. Quenton placement. Emergent plasmaphoresis, no plt transfusion. Transfusion of FFP q6 if plasmaphoresis unable to be performed.

MICU attending:
HUS - quenton catheter to be placed for plasma exchange. Dialysis not warranted at this time.
Surgical procedure
7/22/12 18:30
Quenton catheter placed without adverse events and can be used for plasmaphoresis
Therapeutic Aphoresis Note
7/22/12 22:30
Plasma exchange completed for dx of TTP/HUS. Repeat scheduled for AM.
MICU Night Float Intern
7/22/12 23:10
Was informed that pt had not produced urine over past 7 hrs. It was noted that foley had been removed 2/2 discomfort. We persuaded the patient to have the foley placed again with Ativan given prior to help with agitation. Attempt was unsuccessful.
Urology progress note
7/23/12 23:35
Pt had bloody drainage from catheter after it was placed this morning and flushed with 50cc. Attending on call was contacted about bloody drainage and recommended leaving the catheter in place if the patient's coagulations are normal and to keep patient on Ampicillin and it will resolve with time.
MICU Intern Progress Note
7/23/12 0800
24 hour - patient had one episode of melanotic stool. Plasmaphoresis done. Quenton placed.
Tc 98.9 Tm 99.5 RR 22 HR 70s
SpO2 95% on RA BP 110/66
I/Os +3593/-134
Physical Exam (pertinent)
No physical exam abnormalities noted. A&Ox3

Plan
Continue Ampicillin 2gm IV q12
Continue daily plasmaphoresis, f/u dsDNA, c-ANCA, p-ANCA.
Transfuse 1 unit platelets prior to plasmaphoresis
Anemia likely due to plasma exchange
AKI likely due to TTP
Plan to dialyze patient after plasmaphoresis
Foley was replaced
Hematology Follow Up
7/23/12 0800
Recommendations
TTP/HUS - transfuse 1 unit PRBC before plasma exchange. Repeat labs after PE. Discussed with WHC for possible transfer.
Attending
Bladder scan for evaluation of urethra and bladder
ID Attending
7/23/12 1400
Per ICU team, patient is being transferred to WHC per family wishes. Pt is s/p plasmaphoresis. Continue to monitor CBC, CMP. F/u stool cx, shiga toxin, stool O&P
Renal Progress Note
7/23/12 0700
Physical Exam (pertinent)
Right hand swollen

Plan
Patient to go for dialysis, no fluid removal, for 2.5 hrs.
Therapeutic Aphoresis Note
7/23/12 1600
Plasma exchange #2 completed. Patient to go for dialysis later today.
MICU Intern Progress Note
7/24/12 0800
24 hr — Pt complaining of fullness in bladder

Vitals BP 110/65 Range 96-115/63-75 HR 76-86
RR 15 SpO2 98% RA Tc 98.5 Tmax 100.3
I/O +1350/-535 UOP 20-30

No physical exam abnormalities noted.

Plan
Continue plasmaphoresis and dialysis, thrombocytopenia not improving
Ampicillin d/c'd.
Transfuse if Hb < 8 with either dialysis or plasmaphoresis
Hematology Follow Up
7/24/12 1600
Attending
Pt with HUS typical anemia, stool**?, diarrhea. Plan to transfuse to keep Hb > 10 during dialysis. Pt still for transfer to WHC when bed available.
Renal
7/24/12 0700

Physical Exam
1+ edema

Plan
Dialysis. Consider rheumatology in light of low C3 and C4; however, liver disease and plasmaphoresis could lower complement.
Psychiatry Consult
7/21/12 16:15
Call psych once medical condition has improved and able to communicate freely. Obtain collateral information from family about past psychiatric symptoms.
Urology Consult
7/23/12 0900
Leave foley in place
Ampicillin
Blood will resolve with time
Monitor drainage
Renal Consult
7/21/12
UA
Urine lytes
Avoid nephrotoxics
Hydrate
Adjust meds for renal failure
Peripheral smear
LDH
FANA, dsDNA
C3, C4, CH50
CPK
p-ANCA, c-ANCA
GI Consult
7/19/12
Abd pain with blood and abnormal radiology - consistent with acute exacerbation of chronic inflammatory process vs. acute diarrhea. Pt is on antibiotics for 5 days. Plan for EGD and colonoscopy in the AM.
Hematology Consult
7/22/12
Plasmaphoresis ASAP
May transfuse FFP 2 units q6 until PE arranged.
No platelet transfusion
Haptoglobin, reticulocytes, PE daily, daily labs + fibrinogen, d-dimer.
Surgery Consult
7/21/12
Recommend FFP and platelet transfusion prior to Quenton catheter placement
Please reconsult surgery when thrombocytopenia and coagulopathy corrected.
Discussed with attending
20:15 pm
20:45 pm
22:48 pm
00:30 am
14:00 pm
9:45 am
14:30 pm
10:45 am
23:30 pm
5:00 am
8:30 am
9:30 am
20:45 pm
11:15 am
11:45 am
11:54 am
12:43 pm
13:45 am
16:15 pm
17:00 pm
17:00 pm
18:10 pm
12:00 pm
15:00 pm
10:55 am
7:00 am
7:00 am
17:43 pm
16:00 pm
7:00 am
8:00 am
22:35 pm
23:10 pm
22:30 pm
18:30 pm
13:30 pm
7:00 am
8:00 am
8:00 am
9:00 am
16:00 pm
14:00 pm
7/15
7/16
7/17
7/18
7/19
7/20
7/21
7/22
7/23
7/24
7/25
Timeline created by Patrick A. Woodard
Full transcript