Morbidity mortality conference
This presentation is the property of its rightful owner.
Sponsored Links
1 / 28

MORBIDITY & MORTALITY CONFERENCE PowerPoint PPT Presentation


  • 119 Views
  • Uploaded on
  • Presentation posted in: General

MORBIDITY & MORTALITY CONFERENCE. LATA SHAH, MD VA MEDICAL CENTER ETSU. ADMISSION. Admitted on 6/7/02 Complaints Worsening shortness of breath since recent d/c on 5/30/02 Pedal edema x 1 week. PAST MEDICAL HISTORY. COPD (FEV1-58%) CAD, S/P CABG IN ‘92, HYPERTENSION,

Download Presentation

MORBIDITY & MORTALITY CONFERENCE

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.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Morbidity mortality conference

MORBIDITY & MORTALITYCONFERENCE

LATA SHAH, MD

VA MEDICAL CENTER

ETSU


Admission

ADMISSION

  • Admitted on 6/7/02

  • Complaints

    • Worsening shortness of breath since recent d/c on 5/30/02

    • Pedal edema x 1 week


Past medical history

PAST MEDICAL HISTORY

  • COPD (FEV1-58%)

  • CAD, S/P CABG IN ‘92, HYPERTENSION,

  • H/O CHB S/P PACEMAKER IMPLANTATION

  • CHF WITH LVEF -35% (LATEST ECHO REPORT)

  • CHRONIC RENAL INSUFFIENCY ( BUN/CREAT: 22->30/1.6->2.6)

  • H/O ENTEROCOCCAL BACTEREMIA AND PNEUMONIA

  • H/O PEPTIC ULCER DISEASE AND LOWER GI BLEEDING

  • H/O DEPRESSION


Social history

SOCIAL HISTORY

  • Former Heavy Smoker:

    • Smoked 2PPD for 45 years

    • Quit in 1990’s

    • Lives with wife


Out patient medicines

OUT PATIENT MEDICINES

  • CARDIAC MEDS

    • Aspirin 81mg EC, Atenolol 25mg qd

    • Lasix 40mg po bid, Simvastatin 10mg

  • RESPIRATORY MEDS

    • Methylprednisolone 60mg bid

  • GI

    • Rabeprazole 20mg po qd

    • Multivitam and Calcium

  • ANTIDEPRESSANS

    • Sertralin 50mg po, Trazodone 50mg

  • ANTIBIOTICS

    • Levoflox, flagyl 500mg tid


Physical exam on admission

PHYSICAL EXAM ON ADMISSION

  • Weak elderly gentleman with stable vital signs

  • Raised JVD.

  • Bilateral lower extremities swelling 1 +

  • Respiratory: coarse bilateral rales up to mid thorax and bilateral expiratory wheezing .

  • Cardiovascular: NAD

  • Abdomen: Benign , Peg tube site clean .

  • Neurology : Non focal


Admission labs

ADMISSION LABS

  • CBC:WBC-19.1/Hb-12.2/Plt-227

  • BMP:141/4.2/103/29/22/1.6

  • ABG:7.42/43/64/92.4--- 30%

  • EKG:Paced rhythm @70/mn

  • CXR:Consistent with COPD and CHF


Initial assessment plan

INITIAL ASSESSMENT/PLAN

  • Severe COPD with possible exacerbation:

  • Exacerbation of CHF

  • CRF


Initial managment

INITIAL MANAGMENT

  • Rule out MI

  • Breathing treatments

  • Induce diuresis carefully

  • Panculture

  • Start antibiotics for COPD exacerbation, rocephine + zithromax


Hospital course 1

HOSPITAL COURSE (1)

  • Patient’s condition remained stable for the first 3 days post admission , later on he complained of worsening shortness of breath and had decreased po intake

  • His blood pressure was 96/49 with a HR of 80/mn, advised to increase po intake, lasix was held.

  • Blood culture were positive for MRSA, patient was started on vancomycin, adjusted to renal function.


Hospital course 2

HOSPITAL COURSE (2)

  • ID consult- MRSA bacteremia Cultures: blood/ sputum / urine

  • Cardiology consult- echo

  • General surgery consult- PEG tube


Tee results

TEE - RESULTS

  • Reduced LV function (EF of 25%) with possible apical thrombus

  • No evidence of vegetations on the aortic, mitral or tricuspid valve

  • Pacer wires were fairly well visualized in the RA and RV with no clear evidence of vegetations.

  • Mild AI, mild TR, mild PI.

  • Anticoagulation with Coumadin and lovenox-60mg sc bid started (6/13/02)


Hospital course 3

HOSPITAL COURSE (3)

  • Patient was started on theophylline for COPD

  • Patient was also started on Coumadin for questionable organized LV thrombus


Discharge plan

DISCHARGE PLAN

  • No complaints

  • Vitals stable

  • Labs: INR 1.34

  • Patient’s functional status did not improve much

  • Coumadin education completed


Discharge meds

DISCHARGE MEDS

  • Theophylline 100 mg sa bid

  • Lasix 20 mg qd

  • Warfarin 4 mg qhs

  • Lovenox 60 mg bid till INR therapeutic

  • Linesolide 600 mg bid for 3 weeks


Planned follow up

PLANNED FOLLOW UP

  • Coumadin clinic

  • Home anticoagulation management 6/17/02 with PT / INR

  • ID clinic- 2 weeks

  • IMC clinic with CBC , CMP , Theophylline level on 6/30/02


Patient at home 6 14 6 23

PATIENT AT HOME 6/14 - 6/23

  • Follow up with home health anticoagulation , reported INR was 4.0 (6/17/02) , warfarin dose was 5mg qd Lovenox was continued till 6/17/02 in am

  • Patient instructed to skip one dose of warfarin then alternate 5mg qd with 2.5 mg qd until he receives by mail Coumadin tab dosed at 4 mg then start 4 mg

  • Planned recheck INR in 7 days


Readmission 6 23 02

READMISSION (6/23/02)

  • Admitted to the on-call team over the weekend

  • New complaints:

    • sudden onset of hemoptysis x 2 upon awakening at 3 am with bouts of coughing, small amount with small clots

    • worsening shortness of breath

    • tarry stool since discharge from the hospital

    • no chest pain or fever


Readmission 2

READMISSION (2)

  • BP 107/60, P 85, RR 25,

  • Patient was in moderate distress.

  • HENT: slightly dry mucosa, some blood in the mouth, no JVD.

  • CVS: RRR,no murmurs or gallops.

  • Lungs: diffuse crackles R>L

  • Abdomen: soft, nontender, PEG tube was in situ, +BS

  • Ext:no edema.

  • Rectal exam: stool hemoccult positive, prostate exam was normal


Readmission 3

READMISSION (3)

  • CBC: wbc-9.1 (10.2) / Hb-10.3 (12.9)

  • BMP: bun/creat: 38/1.7

  • INR: 7.67 (4.0 on 6/17/02)

  • ABG: 7.47/38/43/82% @ 32%

  • CXR: with bilateral infiltrates and left lower lobe opacities which are chronic.


Readmission 4

READMISSION (4)

As per admitting team: Assessment & Plan

  • Hemoptysis in a pt with restrictive lung disease and Supratherapeutic INR.

    -drop in 2 gm of HGB last week.

    -get ABG & 3l O2 to keep sat >89%. Breathing Tx

    -will give 2 U FFP to reverse the effect of

    coumadin since pt is still having hemoptysis

    and melena.

    -will stop coumadin and theophyline.

    -H/H q8hrs


Readmission 5

READMISSION (5)

2) Melena: UGI bleed with HIGH INR.

-FFP

-Aciphex

-H/H q8hrs.


Transfer to our team 6 24 02

TRANSFER TO OUR TEAM (6/24/02)

  • AS PER ADMITTING TEAM:

    • Patient was hemodynamically more stable

    • had no more hemoptysis

    • Vitals : P-100/min, RR-28/min, BP-138/53

    • Labs were pending for the morning

    • ABG - 7.43/35/49 at 36% FiO2 : on V-mask with increased O2 to 8L and sats improved to +90%


Reassessment at the bedside

REASSESSMENT AT THE BEDSIDE

  • No c/o hemoptysis, improved since admission as per wife and the patient.

  • Patient c/o worsening shortness of breath.

  • Vitals were stable.

  • Physical exam- patient was breathing at the rate of 28/min, BP138/53, afebrile, pulse 100

  • systemic exam: Resp-bilateral rales heard up to mid thorex with wheezing

  • CVS-tachycardia noted, Abdomen-benign

  • Attending was informed about the transfer of the patient.


Reassessment 2

REASSESSMENT (2)

  • Patient ‘s lungs exam sounded congested

  • As he was receiving NS at 75cc/hr and had received FFP 2units overnight. His IV fluids were stopped and lasix 40mg additional dose was given

  • Attending was informed about the transfer at around 9:15am and we started rounding from this patient


Measures taken

MEASURES TAKEN

  • Blood transfusion planned and was in the process of ordering

    • Nurse called us at 10:50 am informing that Mr.Hill is c/o increasing shortness of breath.

    • While examining him we noticed that he had large black color bowel movement.

    • After that he started deteriorating within few minutes

  • Stat Breathing treatment ordered, repeat ABG was ordered


Measures taken1

MEASURES TAKEN

  • Lasix 40mg IV stat given

  • Repeat PCXR was ordered.

  • Ordered bedside pulse oximeter and tried to titrate up his FIO2 to 80% via V-mask to maintain sats around >88%

  • Lab informed us about Hb of 7.6; Dropped from 10.2 on admission(12.2 on 6/14/02)


Further course

FURTHER COURSE

  • MICU was informed

  • Patient went in to respiratory arrest and died at 12:15

  • Patient was DNR

  • Death was easily accepted by the family at the bedside.

Patient was DNR


  • Login