PHRD 621 - Patient 2, Linda McCarthy

Allergies

Progress Note Day 2

Cardiology Consult Day 2

Infectious Disease Consult Note Day 1

Allergies

H & P Day 1

BMP/CBC | Lipids

Imaging

Cultures

Allergies

BMP/CBC | Lipids

Basic Metabolic Pael

Imaging

Cultures

Allergies

BMP/CMP | Lipids

Imaging

Cultures

Allergies

CBC (w/ differential)

Allergies

Infectious Disease Consult

Infectious Disease Consult Note Reason for Consult/Intervention: Viridans streptococci bacteremia HPI: Ms. McCarthy is a 68 year-old female who presents with fever and general malaise for the past week. BCID2 revealed Viridans streptococci – S. mutans , susceptibilities pending. WBC elevated at 18 on presentation. Patient was started on broad spectrum antibiotics by admitting provider with vancomycin and aztreonam. Current Vitals: BP 148/86 mmHg HR 118 bpm Assessment/Plan: Viridans streptococci Bacteremia • May de-escalate antibiotic therapy, follow up results of TTE to determine if patient has infective endocarditis

Cardiology Consult Note

Reason for Consult/Intervention: Worsening AF/ history of MI/HFrEF HPI: Ms. McCarthy is a 68-year-old female who presented with palpitations, dyspnea, and exertional dyspnea that had been ongoing for the last week. On presentation an EKG revealed that the patient was in atrial fibrillation with RVR. Today the patient reports feeling somewhat better than yesterday, however they are continuing to experience palpitations and shortness of breath from their atrial fibrillation. Current Vitals: BP 134/80 mmHg HR 92 bpm Assessment/Plan: Worsening AF • Patient continues to be in AF with symptoms despite increase in rate control by primary team yesterday • After discussion with patient will initiate dofetilide for conversion and maintenance of NSR as patient would like rhythm control to prevent recurrence of AF in addition to rate control given continued symptoms. The patient endorses understanding risks of rhythm control after our discussion. • May switch patient to oral anticoagulation, decision on agent per primary based on patient now willing to receive anticoagulation CCD/History of MI • Continue current outpatient therapies while admitted

Progress Note

Progress Note Ms. McCarthy is a 68-year-old female who presented with palpitations, dyspnea, and exertional dyspnea that had been ongoing for the last week. On presentation an EKG revealed that the patient was in atrial fibrillation with RVR. Blood cultures were obtained and revealed Viridans streptococci. The patient is currently receiving vancomycin and aztreonam. Today the patient reports feeling somewhat better than yesterday, however they are continuing to experience palpitations and shortness of breath from their atrial fibrillation. Interval Events: • EKG reveals patient has remained in AF, uncontrolled on rate control despite increase of home medication, cardiology has ordered dofetilide • Blood cultures revealed Viridans streptococci- S. mutans, susceptibilities now available • TTE shows vegetation on mitral valve Allergies: penicillin – tongue swelling and shortness of breath Review of Systems: General: Reports some ongoing fatigue, afebrile overnight Cardiovascular: negative for palpitations, in NSR Respiratory: Dyspnea improving Gastrointestinal: No nausea, vomiting, or diarrhea. Neurological: Alert and oriented, mental status at baseline Physical Examination: Temperature: 98.9F Blood Pressure: 134/80 mmHg Heart Rate: 92 bpm Respiratory Rate: 20 breaths/min Oxygen Saturation: 95% on room air General: Clinically improved from yesterday, still symptomatic from AF Cardiovascular: irregular rate and rhythm (atrial fibrillation on repeat EKG) Labs: WBC downtrending (13.7), K 3.2, Mg 2.1, QTc 452 msec Active Medications Enoxaparin 70 mg SQ BID Aspirin 81 mg PO daily Prasugrel 10 mg PO daily Atorvastatin 80 mg PO daily Sacubitril/valsartan 24/26 mg PO BID Carvedilol 25 mg PO BID Bumetanide 1 mg PO daily Dapagliflozin 10 mg PO daily Vancomycin 1000 mg IV q24h Aztreonam 2g q8h Dofetilide 125 mcg PO BID – awaiting verification Sertraline 50 mg PO daily

Assessment/Plan: New Onset Atrial Fibrillation • Patient has remained in AF overnight and is continuing to experience symptoms • Per cardiology recommendations have continued carvedilol • Cardiology placed order for dofetilide to convert and maintain NSR based on SDM with patient • EKG today demonstrates AF with QTc of 452 msec • Patient enoxaparin increased to 70 mg SQ BID for anticoagulation based on slight improvement in renal function, per cardiology can transition to OAC for long term anticoagulation. Will reach out to pharmacy for recommendations. Infective Endocarditis – Viridans streptococci • Presented with general malaise, fever, and elevated WBC, blood cultures on admission revealed Viridans streptococci – S. mutans • TTE completed yesterday revealed a 4.5mm vegetation on the mitral valve and patient diagnosis updated to infective endocarditis • Patient given 1x dose of vancomycin 1500 mg IV in ED. Currently on vancomycin 1000 mg IV q24h in addition to aztreonam 2g q8h for broad spectrum antibiotic coverage • Initial blood cultures finalized. Will collect repeat blood cultures today and work to determine duration of therapy HFrEF • Outpatient medications continued with sacubitril/valsartan, carvedilol, dapagliflozin, and bumetanide CCD/MI with DES • Continue aspirin 81 mg daily and prasugrel 10 mg daily following stent placement 6 months ago for MI • Patient continued on other home medications including sacubitril/valsartan, atorvastatin, and carvedilol Depression • Continue home sertraline DVT prophylaxis • Currently on enoxaparin 70 mg SQ BID, CrCl improved to > 30 mL/min Disposition: Pending clinical improvement

History and Physical

Ms. McCarthy is a 68-year-old female who presents with palpitations, dyspnea, and exertional dyspnea that has been ongoing for the last week. They report initially experiencing these symptoms after spending an afternoon hiking with friends. They have a history of ACS six months ago with stent placement, currently on prasugrel and aspirin, but reports these current symptoms do not remind them of how they felt before their heart attack. The patient does report a history of AF and believes these symptoms are associated with that. They also reports intermittent fevers and malaise over the past week. The patient does not endorse any sick contacts, but did recently have several dental procedures done. On presentation an EKG revealed atrial fibrillation with RVR. Blood cultures were obtained and the patient was started on broad spectrum antibiotics for suspected infection. Past Medical History: HFrEF, Depression, Chronic coronary disease/MI 6 months ago with DES placed Allergies: penicillin – tongue swelling and shortness of breath Family History: Father: Deceased, retired Army veteran, history significant for hypertension, PTSD, T2DM Mother: Deceased from MI, history significant for hypertension, CCD, and T2DM Sister: Alive, resides in Village Green nursing home, patient indicates visiting her 1-2x per month, history significant for stroke, HFrEF, hypothyroidism, gout Social History: Smoking: None Alcohol: Rarely Drug use: None Review of Systems: General: Experiencing fever, chills, fatigue, palpitations and dyspnea, likely multifactorial Cardiovascular: Palpitations, tachycardia Respiratory: Dyspnea present Gastrointestinal: No nausea, vomiting, or diarrhea. Neurological: Lightheaded, fatigue, A&O x 4 Physical Examination: Temperature: 100.9F Blood Pressure: 148/86 mmHg Heart Rate: 118 bpm Respiratory Rate: 22 breaths/min Oxygen Saturation: 96% on room air Cardiovascular: Tachycardic, irregular rhythm noted on exam Extremities: No edema, peripheral pulses 2+ bilaterally Neurologic: Alert, no focal deficits Diagnostic Studies: ECG: Atrial fibrillation with rapid ventricular response ECHO: Pending BCID2: Blood culture positive for Viridans Streptococci – Streptococcus Mutans

Active MedicationsEnoxaparin 70 mg SQ BID Aspirin 81 mg PO daily Prasugrel 10 mg PO daily Atorvastatin 80 mg PO daily Sacubitril/valsartan 24/26 mg PO BID Carvedilol 25 mg PO BID Bumetanide 1 mg PO daily Dapagliflozin 10 mg PO daily Vancomycin 1000 mg IV q24h Aztreonam 2g q8h Sertraline 50 mg PO daily Assessment/Plan: Atrial Fibrillation • Patient presented with symptoms of shortness of breath, fatigue, and palpitations that have been ongoing over last several days. • EKG revealed AF with HR of 118 bpm • Patient initiated onto enoxaparin 70 mg SQ BID for anticoagulation. Previously was not taking any anticoagulation outpatient, but is open to starting therapy during this admission • Will increase patient’s carvedilol to 25 mg PO BID based on this medication previously controlling patient’s AF symptoms • Follow-up tomorrow for further therapeutic adjustments Viridans streptococci Bacteremia • Presented with general malaise, fever, and elevated WBC consistent with patient reported symptoms over last week • Patient given 1x dose of vancomycin 1500 mg IV in ED along with fluid bolus. Will initiate patient on vancomycin 1000 mg IV q24h in addition to aztreonam for broad spectrum antibiotic coverage in the setting of suspected infection • Blood cultures showing Viridans Streptococci – S. mutans pending susceptibilities, TTE ordered HFrEF • Outpatient medications continued with sacubitril/valsartan, carvedilol, dapagliflozin, and bumetanide CCD/MI with DES • Continue aspirin 81 mg daily and prasugrel 10 mg daily following stent placement 6 months ago for MI • Patient continued on other home medications including sacubitril/valsartan, atorvastatin, and carvedilol Depression • Continue home sertraline DVT prophylaxis • Currently on enoxaparin 70 mg SQ daily