Case Presentation Prepared by Jon Manocchio Pharm. D Candidate Ohio Northern University

Patient Information

• Patient: HC

• 100 yom

• DOB: 08.26.1910

• Allergies: PCN, Cephs, Sulfa, Quinolones (can tolerate levofloxacin)

• CC: presented to the ED vomiting and a fever from his nursing home

Problem List

• Pneumonia

• Pancreatitis

▫ Small Bowel Obstruction (SBO)

• Renal Insufficiency

• Hyperglycemia

• N/V

Day 1

Subjective

• HC presents to the ED complaining of vomiting and a fever x 3 days

• PMH: COPD, glaucoma, hypothyroidism, dementia, CHF, anemia, chronic pain, depression, GERD

• SH: nursing home resident

• Cholecystectomy at 58yo

• Patient unable to give much other history

Medication List

• APAP 650mg po q4h prn

• Magnesium 30mL QID prn

• Advair 250/50 1 inh BID

• Alphagan-P i gtt OD daily

• Fludrocortisone 0.1mg po daily

• Potassium Ch 20 mEq po daily

• Lasix 20mg po BID

• Levothyroxine 50mcg po daily

• Namenda 10mg po BID

• Singulair 10mg po daily

• Systane i gtt OU QID

• MTV 1 po daily

• Xalatan i gtt OU qhs

• Colace 100 mg po BID

Medication List

• Metamucil 15mL daily

• Aricept 10mg po daily

• Lexapro 10mg po daily

• Ranitidine 150mg po daily

• Nizoral Shampoo 2% on Mondays and Thursdays

• Risperdal 0.125mg po BID

• Claritin 10mg po daily

• Vicodin 5/500mg 1 po q6h prn pain

• Vitamin B12 1000mcg/mL 1mL IM q month

• Phenergan 25mg/mL 1 mL IM q4h prn nausea

Objective

• Vital Signs

▫ BP 74/46 mmHg

▫ P 104 bpm

▫ R 30 bpm

▫ T 101.2oF

• Labs

▫ sCr 1.4 (0.7-1.2); glucose 202 (65-110); BUN 39 (2-10); amylase 905 (30-110); lipase 1906 (10-60); all others WNL

Objective

• ROS

▫ GI: vomiting

▫ Resp: unlabored, symmetrical

▫ GU: WNL

▫ CV: cap refil <2 secs, no edmea

▫ Neuro: alert, confused

▫ Skin: normal color, dry, hot

▫ Musculoskel: CSM intact

▫ Psycho/Social: calm, cooperative

Objective

• PE

▫ HEENT: PERRL, neck supple with no venous distention

▫ CV: RRR

▫ Lungs: Rhonchi most prominent in rt lower base, crackles in bilateral base

▫ Ab: distended and typanic, bowel sounds absent

▫ Extrem: ¼ distal pulses, no edema

Assessment

• Initial Diagnosis

▫ Acute pancreatitis (SBO)

▫ Hyperglycemia

▫ Pneumonia

• Goals:

▫ Supportive care for pancreatitis

▫ Bring glucose levels back to WNL (70-100)

▫ Begin ATB therapy for pneumonia

Plan

• Begin inpatient medications

▫ Fluids given as 0.9% NS

▫ Morphine IV 2mg/mL prn pain

▫ Ranitidine IV 50mg/2mL q8h

▫ Tylenol 650mg supp pr prn q4h

▫ Ativan IV 2mg/mL prn

• Monitor patient and provide supportive care until further evaluation

Day 2

Objective

• Vital Signs

▫ BP 110/60 mmHg

▫ P 92 bpm

▫ R 30 bpm

▫ T 100oF

• Labs

▫ sCr 3.8 (0.7-1.2); Na 148 (135-145); WBC 12 (3.8-10.8); HgB 12.6 (14-18); amylase 181 (30-110); lipase 85 (10-60); all others WNL

Objective

• PE

▫ HEENT: wnl

▫ CV: RRR

▫ Lungs: air entry equal, prolongation of expiration

▫ Ab: bowel palpable

▫ CNS: sedated

▫ MS: no acute inflammatory signs

Assessment

• Evaluation

▫ Acute pancreatitis (SBO)

▫ Acute Renal Failure

▫ Pneumonia

▫ Acute, worsening dementia

• Goals:

▫ Supportive care for pancreatitis

▫ Monitor and improve renal function

▫ Begin ATB therapy for pneumonia

Plan

• Continue IV hydration

• Begin IV antibiotics for pneumonia

▫ Vancomycin IV 1g/250mL

▫ Levofloxacin IV 25mg q48h Tolerable despite noted allergy

• Bladder and biliary ultrasound

• Monitor TG levels d/t pancreatitis

Day 3

Objective

• Vital Signs

▫ BP 120/60 mmHg

▫ P 90 bpm

▫ R 14 bpm

▫ T 97.8oF

Objective/Assessment

• PE

▫ Lungs: scattered rhonci

▫ CV: RRR

• Resolved SBO

▫ Three bowel movements

• Improved pancreatitis

▫ Decreased levels of amylase and lipase

• Renal insufficiency dramatically worsened

Plan

• D/C Vancomycin

▫ d/t worsening renal function

• Continue to push IV fluids

• Maintain levofloxacin therapy

Day 4

Objective

• Vital Signs

▫ BP 115/64 mmHg

▫ P 86 bpm

▫ R 26 bpm

▫ T 101oF

Objective/Assessment

• PE

▫ Lungs: scattered rhonci

▫ CV: RRR

• Renal function improving (dec sCr)

• Elevated electrolytes

• Maintain hydration therapy

Plan

• Switch IV fluids to D5W

▫ Maintain hydration without increasing electrolytes

• Continue levofloxacin

Day 5

Assessment

• Continued improved renal function

• Rash noted from levofloxacin

▫ Sensitivity

• Pneumonia improving

Plan

• Methylprednisolone 62.5mg q12h

▫ Rash

• Switch from levofloxacin to azithromycin 500mg daily

▫ To prepare for discharge

Day 6

Objective

• Vital Signs

▫ BP 140/68 mmHg

▫ P 65bpm

▫ R 20 bpm

▫ T 97.8oF

• Labs

▫ WBC wnl; HgB and Hct wnl and stable; Na 152 (135-145); BNP 337 (indicative of heart failure)

Objective/Assessment

• PE

▫ Lungs: few rhonci

▫ CV: RRR

• Mostly normalized lab work

• Goals:

▫ Continue po therapy for pneumonia

▫ Prepare for discharge if patient remains stable

▫ Maintain hydration

Plan

• Continue with D5W for hydration

• Re-check labs in 24h before discharge

• Maintain azithromycin for pneumonia therapy

• Follow-up with patient as needed

References

• HC was discharged on Day 7 back to his nursing home

Discharge

Harrison’s Practice. McGraw-Hill Companies, Inc. 2010 Lexi-Comp Online. 2010.