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Morbidity and Mortality Rounds

History. HPI: 53 y.o. Hispanic female admitted through the ER with fever hypotensionh/o diabetes, morbid obesity, CAD 8 years s/p CABG complicated by CVA with residual hemiplegia 1 month PTA admitted with PEPPM placed 3 weeks PTA1 day PTA developed chills, nausea, vomiting. History. PMH:

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Morbidity and Mortality Rounds

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    1. Morbidity and Mortality Rounds Dr. Shounak Das July 27, 2007

    2. History HPI: 53 y.o. Hispanic female admitted through the ER with fever + hypotension h/o diabetes, morbid obesity, CAD 8 years s/p CABG complicated by CVA with residual hemiplegia 1 month PTA admitted with PE PPM placed 3 weeks PTA 1 day PTA developed chills, nausea, vomiting

    3. History PMH: diabetes CAD CVA dyslipidemia PSH: CABG R knee surgery lap choly

    4. History meds (home): aspirin 81 mg daily lisinopril 10 mg daily actos 45 mg daily 70/30 insulin 20 units bid toprol XL 50 mg daily allergies: NKDA

    5. History FH: +ve for diabetes + hypertension SH: married non-smoker; no EtOH

    6. History ROS: denies chest pain or palpitations no cough denies abdominal pain or recent change in bowel habits denies dysuria weight gain is noted she complains of slight headache

    7. Physical Exam Vital signs: HR: 88 (reg) RR: 24 BP: 80/51 T°: 103.4 HEENT: PERRLA/EOMI/anicteric/oropharynx normal/no lymphadenopathy Chest: clear to auscultation bilaterally/mild inflammation around pacemaker pocket; no fluctuance/drainage

    8. Physical Exam CVS: RRR/NL S1 + S2/no extra sounds, rubs, or murmurs Abdo: Nl bowel sounds/ soft, non-tender/no hepatosplenomegaly Neuro: CN II-XII intact/R-sided weakness (U>L) Extremities: +1 bilateral ankle edema Skin: no rashes

    9. Labs

    10. Labs CXR: low volumes; no infiltrate u/a: 25 WBC/hpf blood cultures: 2/2 +ve for MSSA TEE: RA lead – 2-3 mm mobile vegetation/thrombus

    11. started on IV vancomycin initially, then switched to nafcillin once sensitivities confirmed started on pressors intubated hospital day #2 started on CVVHD hospital day #8 for ARF pacemaker removed hospital day #11 MOF; persistent hypotension despite maximal pressors withdrawal of care hospital day # 15 Course in Hospital

    12. Pacemaker Infections incidence roughly 5% 90% of these are “pocket infections” remaining are “deeper infections” i.e. “device –related endocarditis” risk factors: diabetes, recent manipulation of device, temporary pacers 90% caused by s. epidermis or s. aureus 1/3rd “early” (3-6 mos.); 2/3rds “late” (after 3-6 mos.) lead removal recommended for device-related endocarditis

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