Monday, September 15, 2014

Discharge from U of M

This is kind of long and winded with a lot of weird ass medical words and terms. I tried to add a few more simple words or meanings to help out (because I needed to know as well) with some of the difficult ones. Hope you 'enjoy' this, I plan to add my summary papers from Westfields, Regions, and Bethezda as well.. Thanks.

This is my Fairview (U of M) Hosptial Discharge Summary. Dates: 3/21/14 - 4/19/14
I had been at Regions since March 13 until I came [here] to U of M.

Discharge Diagnosis:
Blastomycosis Pneumonia
Acute Respiratory Distress Syndrome (ARDS)
Subarachnoid Hemorrhage

Extracorporeal Membrane Oxygenation (ECMO) - March 21-April 3
Intubation (Breathing tube down my throat) March 18 - April 8
Tracheostomy (Breathing tube now cut into my throat) April 8 - May...? Exercises to help breathe
Percutaneous endoscopic gastrostomy (PEG) Tube Placement -Feeding tube into my belly. April 18 - until mid-June.

CT Scan - Head (Brain) March 25:
Small amount of subarachnoid hemorrhage involving the right high parietal sulci. There is associated scalp hematoma (bleed)  just anterior to the vertex.
Critical Result: Subarachnoid hemorrhage involving the right high parietal lobe.
     *On a more recent side note to this my latest MRI revealed up to 30 brain bleeds revealed in my brain. I go back Sept 16 and 23 for further testing and consulting.

MRI/MRA April 15:
1. Resolving small amount of high right parietal subarachnoid hemorrhage.
2. No intracranial aneurysm is identified.

Discharge Medications:
Amphotericin B lipid 500 mg
Inject 500 mg into the vein every 24 hours
-This the anti-fungal: Extremely toxic, 2nd to chemo

Cetirizine 5 mg tablet
1 tablet by PEG tube route daily
-For allergy, I was allergic to the Amphotericin

Cholecalciferol 50,000 units capsule
Take 1 capsule by mouth three time a week
-Vitamins (Vitamin D) For help with medicine absorptions

Docusate 50 mg liquid, 50 mg by Feeding Tube
Take two times daily
-Bowel regularity (diarrhea)

Guaifenesin-Codeine 100-10 mg/5ml
Take 5 mls by mouth every four hours
-For pain

Hydroxyzine 25 mg tablet
1 tablet by mouth every 6 hours
-For pain and itching

Ipratropium (Albuterol) 0.5 mg
Take 1 vial by nebulization four times daily
-For help with breathing

Intraconazole 10 mg solution
Take 200 mg by PEG Tube two times daily

Labetalol 100 mg tablet
Take 0.5 tablets by mouth every 12 hours
-For blood pressure

Multivitamins with minerals, liquid
Take 15 mls by oral or Feeding Tube daily

Ondansetron (Zofran) 4 mg tablet
1 tablet by mouth every 8 hours
-For nausea

Polyethylene Glycol packet
Take 17 g by Feeding Tube daily
-Bowel regularity (constipation)

Prochlorperazine 5 mg tablet
Take  1-2 tablets by mouth every 6 hours
-For nausea or vomiting

Quetiapine (Seroquel) 500 mg tablet
1 tablet by oral or Feeding Tube 3 times daily
-Sleep aid, anti-psychotic

Ranitidine 150 mg/10 ml syrup
Take by Feeding Tube 2 times daily
 -Reduces stomach acid

Sennosides 8.8 mg/5 ml syrup
Take by Feeding Tube 2 times daily
-Bowel regularity

Vitamin C 500 mg/5ml syrup
Take by PEG tube 2 times daily
-To help absorb acid

Brief History of Illness:
Mike is a 38 yr-old previously healthy gentleman admitted to Regions Hosptial for new onset ARDS in setting of blastomycosis pneumonia. During initial presentation at Regions, patient treated for CAP w/ Azithromycin and Ceftriaxone (commonly treated pneumonia) with no improvement in respiration. Patient represented on March 14, subsequently found to have positive blastomycosis in sputum and started amphotericin therapy. However, on March 18 patient found to have worsening respiratory distress, requiring intubation. Patient remained hypoxic despite ventilator therapy, undergoing pronation and eventual transfer to U of M for ECMO.

Hospital Course:
Blastomycosis pneumonia and ARDS. Patient initially diagnosed with this at Regions Hospital and subsequently started on Amphotericin IV  on March 18. Previous exposures noted upon further history with no immunodeficiency noted on further work-up (HIV negative). Due to worsening respiratory distress, patient intubation on March 18 and reclassified as ARDS due to new chest x-ray findings. However, patient remained persistently hypoxic requiring pronation and on March 21, due to worsening hypoxia, patient started on Hydrocortizone and transferred to U of M for ECMO therapy.

Patient completed ECMO on April 3 with continued improvement in oxygenation on ventilator with additional diuretic therapy and flolan. Patient weaned of flolan and on April 8 underwent tracheostomy placement and started on intraconazole therapy. On day prior to discharge, patient tolerated 6 hous of pressure support therapy.

Drug Rash:
Course complicated by drug rash due to intraconazole on April 12. (This is my son's birthday) Symptoms resolved with supportive cares, undergoing successful intraconazole desensitization therapy on April 17. Patient continued on amphotericin therapy from March 18-present (date of this discharge) with plans to monitor intraconazole levels on current therapy until therapeutic. Will then plan to discontinue amphotericin and continue intraconazole with plans to follow-up to monitor drug levels. Will continue vitamin C at time of intraconazole for further absorption.

Subarachnoid Hemorrhage:
On March 25, patient increasingly agitated with difficulty weaning from additional sedation. CT head demonstrated a small subarachnoid hemorrhage involving the right high parietal sulci. Repeat imaging on March 26 revealed minimal change. Hemorrhage considered secondary to ongoing ECMO therapy in setting of therapy. Patients platelets maintained above 80K, per neuro ICU recommendations. Angiogram on April 18 revealed no additional aneurysms or concerns for mycotic processes.

Acute Kidney Injury:
Patient's creatinine elevated by two. Creatinine continued to increase with contrast exposure on March 14 and initiation of amphotericin on March 18 to peak of 3.6 and new onset of oliguria (low output of urine). Given worsening renal function and oliguria, patient started on CRRT from March 23 - April 5 with subsequent improvement in creatinine and UOP. On day of discharge, patient's creatinine 1.5 with stable urine output of past 24 hrs.

Hypercalcemia: (high calcium in blood)
Elevated during admission, considered secondary to underlying immobilization. Vitamin D low and PTH appropriately low. Per discussion with nephrology, patient started on calcitiol with improvement in hypercalcemia. Continued improved therapy with additional physical/occupational therapies. Will plan to continue to monitor. Start Vitamin D 3 times weekly for 4 weeks.

Patient started on tube feeds during ECMO therapy for additional nutrition. PEG placed with plans to continued tube feeds with goal rate of 70 mL / hr. Will plan to follow nutrition needs, consider additional swallow evaluations when tracheostomy removed.

Condition at discharge:
Improved, stable.
Alert, interactive, fatigued affect.
Trach in place.
Respiratory crackles, no wheezes. Mild tachypnea.
Abdomen - soft, tender LUQ surrounding g-tube site through no erythema or drainage. Midly distended.  No masses, no rebound or gaurding
Skin- Improved rash with dequamation bilaterally, decreased erythema from presentation.
Alert, interactive, communicating non-verbally with mouthing words. Moving extremities against gravity.

Discharge Instructions and follow up:
Diet: Tube feeds
Activity: As tolerated
Follow up with infectious disease in 3-4 weeks
Discharge to rehabilitation facility (Bethezda)

I was transferred to Bethezda on April 19 by ambulance. (No memory of this, but have pictures) My beautiful daughter Scarlett was born April 13.

No comments:

Post a Comment