Progress Note February 12
History and Physical February 11
BMP/CMP | Coag | ABGs
Basic Metabolic Panel
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
+Complete Metabolic Panel
Other
Coagulation Studies
Arterial Blood Gases
BMP/CMP | Coag | ABGs
Basic Metabolic Panel
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
+Complete Metabolic Panel
Other
Coagulation Studies
Arterial Blood Gases
BMP/CMP | Coag | ABGs
CBC (w/ differential)
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
Other
CBC (w/ differential)
CardiacPanel
BMP/CMP | Coag | ABGs
IronStudies
CBC | Cardiac Panel
LipidPanel
Iron | Lipids | Urinalysis
Other
Urinalysis
BMP/CMP | Coag | ABGs
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
Other
Imaging
Infectious Diseases
Blood cultures 2/10 0900
Cardiovascular
Transesophageal Echocardiogram 2/12 0600
Progress Note
Name: Tala Campbell Age: 72 years Sex: Female Chief Complaint: Sent from Primary Care Provider for positive blood culture Past Medical History: hypothyroidism, CKD Stage 2, substance use disorder, IVDU Physical Examination: General Appearance: Alert and oriented x4. Cardiovascular: Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. No suprapubic tenderness. Musculoskeletal: Pulses are present in both feet. Assessment: A 72 year-old female with a history of hypothyroidism, CKD Stage 2, substance use disorder and active IV drug use is admitted with for MRSA bacteremia and opioid induced constipation. Patient reports last bowel movement 2 days ago is on chronic opioids prior to admission for chronic back pain. Plan: MRSA Bacteremia & Endocarditis: TEE positive for triscuspid valve vegetation. Will discontinue vancomycin and start on daptomycin. Will obtain repeat blood cultures and consult infectious diseases. Opioid Induced Constipation: Currently on miralax, will add senna. Follow up bowel movement. Hypothyroidism: Continue home levothyroxine.
Blood Culture
Date: 2/10 Time: 0900
Blood culture: Methicillin Resistant Staphylococcus Aureus Sensitivities Oxacillin: Resistant Vancomycin: Susceptible Daptomycin: Susceptible Clindamycin: Resistant SMX-TMP: Resistant Doxycycline: Resistant
History and Physical
Name: Tala Campbell Age: 72 years Sex: Female Chief Complaint: Sent from Primary Care Provider for positive blood culture Past Medical History: hypothyroidism, CKD Stage 2, substance use disorder, IVDU Physical Examination: General Appearance: Alert and oriented x4. Cardiovascular: Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. No suprapubic tenderness. Musculoskeletal: Pulses are present in both feet. Assessment: A 72 year-old female with a history of hypothyroidism, CKD Stage 2, substance use disorder and active IV drug use is admitted from PCP's office for MRSA bacteremia. Plan: MRSA Bacteremia: On vancomycin pharmacy to dose protocol. Follow up TEE. Hypothyroidism: Continue home levothyroxine.
TEE
Date: 2/11 Time: 0900
Transesophageal Echocardiogram Findings:Large, mobile echodensity measuring 1.6 × 1.2 cm attached to the atrial aspect of the tricuspid valve anterior leaflet, consistent with valvular vegetation.Severe tricuspid regurgitation with evidence of leaflet destruction.Impression:Findings are diagnostic of infective endocarditis involving the tricuspid valve.
Tala Campbell
Grace
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Transcript
Progress Note February 12
History and Physical February 11
BMP/CMP | Coag | ABGs
Basic Metabolic Panel
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
+Complete Metabolic Panel
Other
Coagulation Studies
Arterial Blood Gases
BMP/CMP | Coag | ABGs
Basic Metabolic Panel
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
+Complete Metabolic Panel
Other
Coagulation Studies
Arterial Blood Gases
BMP/CMP | Coag | ABGs
CBC (w/ differential)
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
Other
CBC (w/ differential)
CardiacPanel
BMP/CMP | Coag | ABGs
IronStudies
CBC | Cardiac Panel
LipidPanel
Iron | Lipids | Urinalysis
Other
Urinalysis
BMP/CMP | Coag | ABGs
CBC | Cardiac Panel
Iron | Lipids | Urinalysis
Other
Imaging
Infectious Diseases
Blood cultures 2/10 0900
Cardiovascular
Transesophageal Echocardiogram 2/12 0600
Progress Note
Name: Tala Campbell Age: 72 years Sex: Female Chief Complaint: Sent from Primary Care Provider for positive blood culture Past Medical History: hypothyroidism, CKD Stage 2, substance use disorder, IVDU Physical Examination: General Appearance: Alert and oriented x4. Cardiovascular: Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. No suprapubic tenderness. Musculoskeletal: Pulses are present in both feet. Assessment: A 72 year-old female with a history of hypothyroidism, CKD Stage 2, substance use disorder and active IV drug use is admitted with for MRSA bacteremia and opioid induced constipation. Patient reports last bowel movement 2 days ago is on chronic opioids prior to admission for chronic back pain. Plan: MRSA Bacteremia & Endocarditis: TEE positive for triscuspid valve vegetation. Will discontinue vancomycin and start on daptomycin. Will obtain repeat blood cultures and consult infectious diseases. Opioid Induced Constipation: Currently on miralax, will add senna. Follow up bowel movement. Hypothyroidism: Continue home levothyroxine.
Blood Culture
Date: 2/10 Time: 0900
Blood culture: Methicillin Resistant Staphylococcus Aureus Sensitivities Oxacillin: Resistant Vancomycin: Susceptible Daptomycin: Susceptible Clindamycin: Resistant SMX-TMP: Resistant Doxycycline: Resistant
History and Physical
Name: Tala Campbell Age: 72 years Sex: Female Chief Complaint: Sent from Primary Care Provider for positive blood culture Past Medical History: hypothyroidism, CKD Stage 2, substance use disorder, IVDU Physical Examination: General Appearance: Alert and oriented x4. Cardiovascular: Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. No suprapubic tenderness. Musculoskeletal: Pulses are present in both feet. Assessment: A 72 year-old female with a history of hypothyroidism, CKD Stage 2, substance use disorder and active IV drug use is admitted from PCP's office for MRSA bacteremia. Plan: MRSA Bacteremia: On vancomycin pharmacy to dose protocol. Follow up TEE. Hypothyroidism: Continue home levothyroxine.
TEE
Date: 2/11 Time: 0900
Transesophageal Echocardiogram Findings:Large, mobile echodensity measuring 1.6 × 1.2 cm attached to the atrial aspect of the tricuspid valve anterior leaflet, consistent with valvular vegetation.Severe tricuspid regurgitation with evidence of leaflet destruction.Impression:Findings are diagnostic of infective endocarditis involving the tricuspid valve.