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193_SECTIME11 Lasix 2014-04-09 "Admission Date : 2014-03-31 Discharge Date : 2014-04-09 Service : Liver Transplant Surgery Service HISTORY OF PRESENT ILLNESS : The patient is a 49 year-old man with hepatitis C cirrhosis complicated by encephalopathy , positive esophageal varices , now with worsening confusion and lethargy . The patient has been admitted 5 x in the past to Nantucket Cottage Hospital since 11-30 for encephalopathy . Most recently admitted on 2014-03-19 to 2014-03-22 . Infectious work-up was negative . Trazodone stopped . Patient was started on Lactulose and Rifaximine which improved his mental status . Today , on 2014-03-03 , the patient was seen in clinic with increased lethargy , confusion . Wife reports that the patient has a history of lethargy and confusion , similar to the symptoms for which the patient was recently admitted . The patient also reports that he has had "" yellowish eyes , some shaking and his breath smelled more like ammonia over the past 3 days ."" The patient has been compliant with his medications . He has had one bowel movement today which is on 2014-03-31 . He has had night sweats for the past 2 weeks . He denies any abdominal pain . He gets cold easily but denies fevers . His stools have been brown to green . HOSPITAL COURSE : The patient was admitted . Patient continued on Lactulose . The goal was 3 to 4 stools per day . Continue on Rifaximine . Continue Lasix . Physical therapy was consulted on 2014-04-01 . On 2014-04-02 , the patient was awake , alert and oriented , taking Lactulose . Difficulty with word finding at times . Denies any pain or discomfort . Abdomen : Slightly distended , nontender . Positive bowel sounds . Positive flatus . Good op site . Ultrasound was performed on 2014-04-01 demonstrating severe portal hypertension with massive peri splenic varices and splenorenal shunt . Portal vein was fully patent . Repeat hepato fungal flare . On 2014-04-04 , the transplant service was consulted because the patient was possibly going to the operating room for transplant on 2014-04-04 . The patient did go to operating room on 2014-04-04 and the patient had cadaveric liver transplant performed by Dr. Michael Sanders . Please see detailed operative note for more information about the procedure . Postoperatively , the patient was transferred to the ICU . The patient received MMF 1 gram b.i.d. , Flagyl 500 mg IV x1 . The patient also received Unasyn for 2 days , Fluconazole , heparin , Protonix , insulin , morphine , Bactrim . The patient was on Propofol for 2 days . LABORATORY DATA : On 2014-04-04 , labs were as follows : WBC of 8.3 ; hematocrit of 30.6 ; platelets 69 ; sodium 132 ; 3.9 , 102 , 22 , serum creatinine of 13 and 1.1 . Glucose 114 . AST 87 . ALT 44 . Alkaline phosphatase 169 . PT of 20.6 . PTT of 38.7 . INR of 2.0 . On postoperative day number 1 , duplex ultrasound of the patient 's liver was performed demonstrating normal appearing portal veins and hepatic arteries . There was normal flow within the middle hepatic vein . There appears to be a decreased and sluggish flow within the right and left hepatic veins with loss of normal respiratory variations , wave forms and the intrahepatic portion . Additionally , there is diminished color flow with confluence of the hepatic veins . These findings may reflect thrombus within the left and right hepatic veins . Caval narrowing is seen , most likely correlation to clinical history is recommended and further evaluation of the CT or short-term ultrasounds for follow-up was recommended . The Feeney Gann-Burlington drain on postoperative day number demonstrated medial output of 780 with lateral output of 150 . Patient went to the floor and patient was on the floor on 2014-04-07 . Patient continued getting Acyclovir , Prednisone , MMF one gram b.i.d . The patient was on FK 2 and 2 that was started on postoperative day number 2 . Diet was advanced . Patient was ambulating . Waltham-Ludlow drains put out on the 13th 620 and 380 . Physical therapy was re consulted . Omalley was consulted on 2014-04-08 for better glucose control since the patient was on steroids . Social work was consulted . Patient continued to do very well , ambulating , following the diet . Patient was transfused 1 unit of platelets on 2014-04-08 for platelet count of 66 . A heparin independent antibody was sent off on 2014-04-07 which was unremarkable . On 2014-04-09 , patient continued to do very well , ambulating , tolerating a diet , urinating without difficulty . Drains continued to put out significant amount of fluid . Patient 's labs from 2014-04-10 were the following : 7.1 , hematocrit of 30.8 , platelets 90 . Sodium of 138 ; potassium 3.5 ; 106 , 28 , 31 , 1.0 , glucose 134 . AST 82 . ALT 176 . Alkaline phosphatase 78 which all have significantly decreased since postoperative day number 1 . Total bilirubin was 0.9 . On 2014-04-09 , FK level was 10.3 . Patient left on 2014-04-09 with VNA to home ." BEFORE "Admission Date : 2014-03-31 Discharge Date : [@Object$]2014-04-09[@Object$] Service : Liver Transplant Surgery Service HISTORY OF PRESENT ILLNESS : The patient is a 49 year-old man with hepatitis C cirrhosis complicated by encephalopathy , positive esophageal varices , now with worsening confusion and lethargy . The patient has been admitted 5 x in the past to Nantucket Cottage Hospital since 11-30 for encephalopathy . Most recently admitted on 2014-03-19 to 2014-03-22 . Infectious work-up was negative . Trazodone stopped . Patient was started on Lactulose and Rifaximine which improved his mental status . Today , on 2014-03-03 , the patient was seen in clinic with increased lethargy , confusion . Wife reports that the patient has a history of lethargy and confusion , similar to the symptoms for which the patient was recently admitted . The patient also reports that he has had "" yellowish eyes , some shaking and his breath smelled more like ammonia over the past 3 days ."" The patient has been compliant with his medications . He has had one bowel movement today which is on 2014-03-31 . He has had night sweats for the past 2 weeks . He denies any abdominal pain . He gets cold easily but denies fevers . His stools have been brown to green . HOSPITAL COURSE : The patient was admitted . Patient continued on Lactulose . The goal was 3 to 4 stools per day . Continue on Rifaximine . Continue [@Subject$]Lasix[@Subject$] ." BEFORE |
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121_TL272 both extended and internally rotated increased throughout ADMISSION DATE : 09-07-93 DISCHARGE DATE : 09-08-93 PATIENT DIED ON 9/8/93 . HISTORY OF PRESENT ILLNESS : Date of birth : 10/4/88 . This patient is a 5 year old white female with a history of type I renal tubular acidosis on nephrocalcinosis who was admitted to Noughwell Entanbon Health of Washington on 9/5/93 at 21:16 hours with a 2-3 day history of chills , fevers , cough , vomiting and weakness ( unable to walk ) . At Noughwell Entanbon Health , her temperature was 101 , pulse 135 , blood pressure 94/74 , respiratory rate 20 . Positive findings of physical examination include chicken pox lesions on thorax , sunken eyes , thick nasal discharge , dry lips , tongue and mucous membranes , red tonsils . The remainder of the physical examination was considered within normal limits . Admission diagnosis at Ni Hospital and apos;s : vomiting and dehydration , hypokalemia , hyponatremia , tonsillitis . A peripheral intravenous line was started on Labor Day in the a.m. No respiratory distress was noted . Oral cyanosis and shallow respirations were noted on 9/7/93 at 2:45 a.m. Therefore the patient was intubated at 3:45 a.m. on 9/7/93 . Chest x-ray was unremarkable . Cardiovascular stable , significant hypertension was noted on 9/7/93 at 5:10 a.m. and therefore 10 cc and apos;s per kilo albumin was given . The patient was admitted was started on clear fluids , tolerated , with D5 normal saline plus 40 mEq per liter of KCL at a rate of 50 cc and apos;s per hour for 9 hours . ( 100 cc and apos;s per kilo ) . Sodium and potassium at this time were 128/1.5 . At Labor Day , 9:30 a.m. , the fluids were increased to 100 cc and apos;s per hour ( 200 cc and apos;s per kilo for 5 hours ) . Electrolytes at this point were sodium 132 , potassium 1.8 . At 9/6/93 , 2:30 p.m. , fluids were decreased to 75 cc and apos;s per hour , 150 cc and apos;s per kilo , 40 mEq of K phosphate added to the intravenous fluids . Electrolytes at this point were a sodium of 143 and potassium 1.7 . On 9/6/93 , 22:00 , fluids were changed to D5 normal saline plus 40 KCL and 40 K phosphate at 75 cc and apos;s per hour . This rate was maintained for 11 hours . Electrolytes at this time were a sodium of 148 , potassium 1.7 . At 9/7/93 , 1:00 a.m. , intravenous fluids rate was decreased to 50 cc and apos;s per hour , total fluids given during the first 24 hours were 140 to 150 cc and apos;s per kilo per day . At this time , sodium was 147 , potassium 2.6 , total sodium given during the first 24 hours 20 mEq per kilo per day . On 9/7/93 at 4:00 a.m. , albumin bolus 5% 10 cc and apos;s per kilo was given , a total of 120 cc and apos;s , electrolytes were sodium 155 , potassium 3.1 . At 9/7/93 at 5:00 a.m. , sodium bicarbonate given 60 mEq , calcium bolus 10 cc and apos;s given . On 9/7 , 5:30 a.m. , D5 quarter normal saline , and 40 of K phosphate at 100 cc and apos;s per hour was given . The patient was taking PO initially until 9/6/93 at 17:45 . There were no abnormal findings in abdominal exam . On 9/5/93 , hematocrit 48 , white blood count 11.2 , neutrophiles 67 , bands 14 , lymphs 11 , monos 6% , meta 2% , platelets 220,000 . Copious urine output , BUN 1.0 , creatinine .8 . Normal neurologic exam on admission , then lethargic on 9/6/93 at 17:45 , then patient became unresponsive , areflexic and limp at 9/6/93 , at 17:45 to 22:00 . Patient was having seizures , twitching of face and rapid movements of eyes . Pupils dilated and sluggish . Valium was given at 9/7/93 , 00:02 . IV ampicillin , chloramphenicol , ceftriaxone , and culture were sent . Finally , Fairm of Ijordcompmac Hospital transport team was called and transport team arrived on 9/7/93 , 6:30 a.m. , and on arrival patient was seizing with rhythmic eye movement to left . The patient was unresponsive , poor perfusion . Temperature was 101.8 . A second intravenous was started and given normal saline bolus , change in intravenous fluids to D5 water with 80 mEq of bicarbonate , plus 40 mEq of KCL at 45 cc and apos;s per hour , bicarbonate given 2 mEq per kilo , attempted to start dopa for poor perfusion but worsening perfusion . Therefore , dopa was stopped . Total volume given as bolus 50 cc and apos;s per kilo , sodium bicarbonate at 2 mEq per kilo was given . Last ABG there was 6.98 , 31 , 171 , bicarbonate of 7 . Phenobarbital and Dilantin given for seizure control . Electrolytes before departure for Fairm of Ijordcompmac Hospital was a sodium of 176 , potassium 2.5 , chloride 140 , bicarbonate 14 , calcium 7.2 , magnesium 2.7 . Admission to the Pediatric Intensive Care Unit at Fairm of Ijordcompmac Hospital was 9/7/93 , 11:15 a.m. Lines placed were a right femoral triple lumen , endotracheal tube 4.0 , arterial line , right radial line , Foley placed , peripheral intravenous line , nasogastric tube . On admission to Fairm of Ijordcompmac Hospital , temperature 100.2 , pulse 149 , respiratory rate 50 , blood pressure 98/66 , mean arterial pressure of 73 , weight 12 kilos . HOSPITAL COURSE : On admission , FI02 was 50-60% , PID 30-32/PEEP of 5.7 , total volume was between 140 to 210 during Intensive Care Unit stay . Chest x-ray showed right upper lobe pneumonia . Cardiovascular : CVP on admission was 1 cm of water . Then during the Intensive Care Unit stay , the CVP remained between 7 to 8 after volume resuscitation . Dopamine and epinephrine given for cardiovascular support . Her electrocardiogram findings were compatible with hypokalemia ( flattening T waves and ST changes ) . Fluids / electrolytes/nutrition : On admission to Fairm of Ijordcompmac Hospital , hypernatremia and hypovolemic shock . Fluids of D5 water with 30 mEq of sodium acetate per liter , 30 ml per liter of phosphate , and 30 mEq of K acetate per liter at 90 cc and apos;s per hour was given . Free water deficit over 48 hours was given , plus maintenance , plus adjusting the ongoing losses . Pediatric Nephrology recommended on 9/7/93 , 5:50 p.m. , 10 cc and apos;s per kilo of 150 mEq of sodium bicarbonate per liter , ( 1.5 mEq per kilo bicarbonate , one dose of Lasix and volume as needed ) . The patient required multiple boluses of albumin for hypotension , patient also required multiple boluses of calcium because of hypocalcemia and hypotension . Magnesium 2.0 mEq per liter , phosphate 8 mg / dl . Gastrointestinal : Normal . NPO . Albumin was 4.9 . Globulin was 1.6 , uric acid was 6.5 , alkaline phosphatase 150 , SGPT 11 , SGOT 85 , LDH 524 , CK 152 , NH3 81 . Hematologic : White cell count 9.4 , hematocrit 42 , platelets 151,000 . Differential was polys 59 , bands 3 , lymphs 25 . Repeat white cell count 6.4 , hematocrit 34 , platelets 103 . PT 11.6/10.1 , repeat PT 12.8/10.5 . PTT 36.4 , repeat PTT 50.9 . Fibrinogen 211 . Renal : Urine output was about 5 to 8 cc and apos;s per kilo per hour . Renal ultrasound was scheduled during the Intensive Care Unit stay . Urinalysis showed specific gravity 1.005 , pH 8.0 , positive proteins , positive red blood cells , negative white cell count , positive glucose . Neurologic : Patient did not receive sedation or muscle relaxant since admission to the Pediatric Intensive Care Unit . Phenobarbital levels were 31.4 , 30.2 , and 50 . Dilantin level was 22.6 , 20.2 , 20 . Neurology consultation on the evening of 9/7/93 revealed supple neck , no response to external rub . Pupils were 3.5 OD , and 3.0 OS , irregular and non reactive . Corneal reflexes and oculocephalic reflexes were absent . There was no gag . Muscle tone was increased throughout , and the legs were both extended and internally rotated . Deep tendon reflexes could not be elicited and plantar responses were silent . Repeat neurological examination revealed no spontaneous movement and no response to voice or noxious stimulation . Pupils were dilated and non reactive . Disc margins appeared blurred on funduscopic exam . A non contrast head CT scan was obtained and CT revealed severe cerebral edema with thalamic mid brain , pons , medullar low attenuation , diffuse cerebral edema , loss of gray white matter differentiation . Cerebral blood flow was done on 9/7/93 at 2:30 p.m. , revealed complete absence of blood flow to brain . There was a tiny region of activity in what appears to be anterior scalp . Infectious Disease : Ampicillin and chloramphenicol were given at Noughwell Entanbon Health , and ceftriaxone was given at Fairm of Ijordcompmac Hospital . Acyclovir was started , also considering the varicella at 120 mg intravenously every 8 hours . Urine cultures , blood cultures and sputum cultures were sent . The patient finally died . The situation of the patient was extensively discussed with the parents , and the attending physician from Neurology , Dr. Breunkote , and the attending physician from Pediatric Intensive Care Unit , Dr. Boormcose , and the decision was finally made with the family and attendings to disconnect the patient from the mechanical ventilation due to severe neurological injury and poor prognosis . ZAKAY COUGH , M.D. TR : jx / bmot DD : 10-20-93 TD : 10/21/93 CC : edited 10/24/93 rc OVERLAP Muscle tone was [@Object$]increased throughout[@Object$] , and the legs were [@Subject$]both extended and internally rotated[@Subject$] . OVERLAP |
