433651389
CTMC
81247987
625670
08/16/1998 12:00:00 AM
MENTAL STATUS CHANGE , CELLULITIS
Signed
DIS
Admission Date :
08/16/1998
Report Status :
Signed
Discharge Date :
08/18/1998
PRINCIPAL DIAGNOSIS :
MENTAL STATUS CHANGES .
OTHER DIAGNOSES :
1) AORTIC STENOSIS .
2) MITRAL REGURGITATION .
3) STATUS POST FALL .
4) HISTORY OF TRANSIENT ISCHEMIC ATTACK / CEREBROVASCULAR ACCIDENT .
5) RIGHT LOWER EXTREMITY WOUND .
6) ATRIAL FIBRILLATION .
HISTORY OF PRESENT ILLNESS :
The patient is an 88 year-old woman undergoing treatment for a right lower extremity cellulitis who was transferred from Child for worsening cellulitis and new confusion .
The patient has a history of severe aortic stenosis and was recently admitted to the Retelk County Medical Center for a Nafcillin sensitive Staphylococcus aureus cellulitis of the right leg treated with a course of Nafcillin and Levofloxacin .
There was also a right leg fluid collection that was incised and drained on August 1 , 1998 .
The patient was sent to rehabilitation on Levofloxacin orally .
Although details were not available at the time of admission , apparently , she had done well until the 24 hours proceeding admission when the cellulitis was felt to be worsening .
She had also been noted to be confused and combative during that 24 hour period .
As her baseline mental status is completely alert and oriented , this caused concern amongst the staff of the rehabilitation center and the patient was transferred to the Retelk County Medical Center .
PAST MEDICAL HISTORY :
1) Aortic stenosis , severe , echocardiogram in July of 1998 with a peak gradient of 6-8 mm of mercury , aortic valve area calculated to be 0.5 cm squared by the continuity equation .
The patient has a history of congestive heart failure .
Calculated ejection fraction was 45-50% .
2) Mitral regurgitation , 2+ on July of 1998 echocardiogram .
3) History of atrial fibrillation .
4) History of cerebrovascular disease .
5) Hypertension .
6) History of temporal arteritis on chronic steroids .
7) History of colitis .
8) History of vertebral body fractures .
MEDICATIONS ON ADMISSION :
1) Digoxin 0.125 mg p.o. q. day .
2) Lasix 80 mg p.o. b.i.d.
3) Aspirin 81 mg p.o. q. day .
4) Coumadin 2 mg p.o. q.h.s.
5) Zaroxolyn 2.5 mg p.o. q. day .
6) Toprol XL 50 mg p.o. q. day .
7) Potassium 20 mEq p.o. q. day .
8) Prednisone 5 mg p.o. q.o.d.
9) Fosamax 10 mg p.o. q. day .
10) Levofloxacin 250 mg p.o. q. day .
11) Axid 150 mg p.o. b.i.d.
12) Buspar 5 mg p.o. t.i.d.
13) Zyrtec 10 mg p.o. q. day .
ALLERGIES :
The patient had no known drug allergies .
SOCIAL HISTORY :
The patient is presently staying at the Gangistown Hospital Center .
She has a son who is actively involved in her care .
PHYSICAL EXAMINATION :
Physical examination on admission revealed an elderly woman , sleeping , responsive only to noxious stimuli after having received some sedation in the emergency department .
Vital signs :
Heart rate 60 , respiratory rate 18 , blood pressure 116/80 , temperature 97.1 degrees , oxygen saturation 93% on room air .
Head and neck examination was benign .
Skin examination was notable for a leg ulcer and cellulitis to be delineated below .
There were no spider angiomata .
Neck was supple with no thyromegaly .
Lungs were clear to auscultation bilaterally .
The heart examination revealed that the patient had a sustained PMI which was located in the left mid clavicular line , S1 , near complete obliteration of the second heart sound by a two out of six high pitched murmur peaking at mid to late systole and heard across the precordium .
It radiates to both carotids bilaterally .
There was also a blowing holosystolic murmur heard at the patient 's apex to axilla .
There was no S3 appreciated .
Vascular examination was notable for 1+ carotid impulses which were diminished and delayed and the above mentioned transmitted cardiac murmurs .
Abdominal examination revealed that the abdomen was soft , non-tender , non-distended , no organomegaly , no masses , normal active bowel sounds .
The patient 's extremity examination was notable for erythema of the right calf with a small ulcer with a relatively clean base .
Neurological examination revealed that the patient was quite sedated at this time having received some medications .
She was arousable only to painful stimuli .
Her pupils were reactive bilaterally .
Her face was symmetric .
She had an intact gag reflex .
She was able to move all four of her extremities in response to pain .
Her deep tendon reflexes were slightly diminished at 1+ bilaterally , but symmetric .
LABORATORY :
The patient 's laboratory data on admission is as follows :
Sodium was 142 , potassium 3.3 , chloride 99 , BUN 23 , creatinine 1.1 .
AST was 25 , alkaline phosphatase 130 , total bilirubin 3.2 , albumin 3.4 , calcium 8.8 .
Digoxin level was 0.8 .
Hematocrit was 33.0 , platelet count 627 , white blood cell count 10,000 , MCV 79.8 .
Coagulation studies revealed a PT of 17.4 seconds with an INR of 2.1 , PTT 25.5 .
The patient 's admission chest x-ray revealed no infiltrate , no congestive heart failure .
Head CT scan performed in the emergency department revealed no bleed .
Urinalysis revealed trace microscopic hematuria with 47 red blood cells per high powered field , 1+ bacteria .
HOSPITAL COURSE :
1) Mental status changes :
On admission to the emergency room , the patient was somewhat argumentative and confused as well as uncooperative with procedures .
A neurologic work-up was undertaken which included a CT scan of the head which revealed no acute bleed and a lumbar puncture which revealed a glucose of 72 , protein 65 , white blood cell count 19 , red blood cell count 11,500 with no evidence of xanthrochromasia .
The Neurology Service evaluated the patient who felt that her agitation was most likely due to infection , her multiple medications , or her metabolic condition .
The patient 's mental status slowly began to recover , however on the morning of the first day of admission , August 16 , 1998 , the patient was found after having fallen .
A neurological examination was performed which revealed no abnormality and imaging included a head scan which revealed no bleed and a cervical spine series which revealed degenerative joint disease but no obvious fracture .
The patient decided not to pursue further testing with a neck CT scan .
At the time of discharge , the patient 's mental status is back to its baseline .
2) Right lower extremity cellulitis :
The patient was evaluated by the Surgical Service who felt that the wound was clean with some erythema but without evidence of true cellulitis .
The patient 's antibiotics were discontinued with the thought that prolonged antibiotics only put her at more risk for infection .
3) Cardiac :
The patient has a history of critical aortic stenosis and mitral regurgitation .
Fortunately , these issues were not active during the present admission .
4) Status post fall :
The patient did fall while inhouse .
A head CT scan and cervical spine series were negative .
The patient appeared to have no deficits at the time of discharge .
5) Atrial fibrillation :
The patient 's Coumadin was continued .
6) Abnormal liver function tests :
On admission , the patient was noted to have elevated bilirubins in the 3 range and mildly elevated alkaline phosphatase consistent with a cholestatic picture .
These liver function tests will be followed closely as an outpatient .
MEDICATIONS ON DISCHARGE :
1) Aspirin 81 mg p.o. q. day .
2) Digoxin 0.125 mg p.o. q. AM .
3) Lasix 40 mg p.o. b.i.d.
4) Zaroxolyn 0.25 mg p.o. q. day .
5) Prednisone 5 mg p.o. q.o.d.
6) Coumadin 2 mg p.o. q.h.s.
7) Kay Ciel 20 mEq p.o. q. day .
8) Fosamax 10 mg p.o. q. day .
9) Amitriptyline 10 mg p.o. q.h.s.
10) Buspar 5 mg p.o. t.i.d.
FOLLOW-UP :
The patient will be followed at rehabilitation by her primary care physician , Dr. Both .
Dictated By :
TIA BREUNMULL , M.D. OH29
Attending :
RA S. BOTH , M.D. YT79 WH234/2364
Batch :
4025
Index No. FSYAMR79X6
D :
08/18/98
T :
08/18/98