DateofHistory&Exam:2/5/15

Patient:B.J.,46y.o.Caucasianfemale;Patientisthehistorianprovidingtheinformation.

SUBJECTIVE:
Chiefcomplaint:fever,fatigue,malaiseandshortnessofbreath

HPI:Mrs.Johnisa46yearoldCaucasianfemalewithaPMHxofSLE(15yrs.)&chronic
AtrialFibrillation(2yrs.).Mrs.JohnpresentstotheEDtoday,afterthreesdaysofworsening
fever,fatigue,malaise,andprogressivedifficultycatchingherbreath.Ptnotedagradualonset
offeverwithaTmaxof99.7Foverthepast24hours,fatigueandgeneralmalaisefeeling
followedbyanonetimeepisodeofsharppleuriticchestpain(6/10)on2/4/15withinspiration
whileclimbingstairs.Ptsatdownandthesharpchestpainfeelingwentawaybutthefever,
fatigueandshortnessofbreathhavebeenpersistentsince.Shealsoreportsanonproductive
coughPtstatesthisepisodeisdifferentthanherpriorSLEexacerbationssoshedecidedto
presenttotheEDduetoincreasedshortnessofairandfatigue.Ptdenieschestpain,nausea,
vomitingandpalpations.Currently,SLEisbeingmanagedwithImuranmgBIDandAtrial
FibrillationisbeingmanagedwithWarfarin4mgforagoalINRof2.53.5.Admitsto
compliancewithmedsandthelastdosesofImuranandCoumadinweretakentoday(2/5/15)at
0700.
Pending:STATCXR&EKG
Labs:ABG,CBC,BMP,PT/PTT/INR,Troponin,DDimer,Creactiveprotein,LDHlevel,
sedimentationrate,BloodCulturesX2,SputumCulture&InfluenzaSwab
VS(Triage):BP106/75,HR122AFIB,RR24,SpO291%%RA,T.99.4F
Pain4/10ChestHeight:54,Weight=143lbs.BMI:24.5

PastMedicalHistory:
Currentmedicaldiagnoses:
SLE(12/2000)
AtrialFibrillation(10/2013)
Hospitalizations/Surgeries:
Appendectomy5/1996
SLEExacerbation3/2001
AtrialFibrillation10/2013
CurrentMedications(providedbypatient):
Metoprolol25mgPOtwicedaily
CentrumUltraWomensOTCMultivitamin1tabletPOoncedaily
Tylenol500mg(OTC)2tabletsPOPRNforheadache(typicallyonceaweek)
Imuran132mgPOdaily
Coumadin4mgPOdaily
Allergies:
NKDA

 Nocontrast,iodine,orfoodallergies.
SocialHistory:
Tobacco:40packyearhistory.Resumedsmokingafterrecentdischarge.
Alcohol:Socialuse,12mixeddrinksontheweekendswithfriends.
Illicit/Recreationaldrugs:Deniesillicitorrecreationaldruguse.
Maritalstatus:Divorced.
Children:One26yearolddaughterwholivesoutoftown.
CodeStatus:Patientisafullcode.Livingwillanddurablepowerofattorney(daughter)on
filefrompriorhospitalization.

FamilyHistory:
SLE:Mother
CVA:Mother(FatalHemorrhagicCVAage76).PGM
COPD:Father,MGF
CAD:Father(FatalMIage64),Mother,MGF,
AFIB:PGF

ROS:
General:Priortothisevent,thepatientbelievessheisinfairhealth,stating:Ifeltokuntil
theotherday,justalittletiredwhichisnormalforme.
HEENT:Patientreportsoccasionalmouthsores.Deniesahistoryofsorethroat,earaches,
headache,vertigo,orepistaxis.Patientwearslowerpartialdentureplatethatiscurrentlyin
place.
Cardiovascular:SeeHPI.Atrialfibrillationw/RVR(HR122)managedwithCoumadin
andMetoprolol.Patientreportshistoryofepisodicpalpations.Deniesahistoryof
palpitationsoverthelastyear,syncope,edema,cramps,legpainorvaricoseveins.
Respiratory:SeeHPI.Endorsesdyspneaandshortnessofbreathatrestandwithactivity.
Reportsoccasionalnonproductivecough.Deniesahistoryofwheezing,COPD,pneumonia
orasthma.
Gastrointestinal:Deniesahistoryofdysphagia,nausea,vomiting/hematemesis,GERD,
heartburn,diarrheaorconstipation.
Genitourinary:Deniesahistoryofdysuria,polyuriaorhematuria.
Neurological:Deniesahistoryofsyncope,seizures,weakness,numbness,tingling,tremors
ormemorychanges.
Endocrine:Deniesahistoryofdiaphoresis,heatorcoldintolerance.
Heme/Lymph/Immun:SeeHPI.SLEmanagedbyImuran.Patientreportsincreasing
fatigue,feverandageneralfeelingofmalaise.Deniesahistoryofeasybruisingorbleeding,
nopriortransfusions.Deniesweakness,chillsandnightsweats.
Objective:
Constitutional:Wellkeptwomaninmoderatedistress.Skiniswarm,pinkanddry.
VS:BPL116/75,HR122AFIB,RR24,SpO296%%6L/NC,T.99.4FPain0/10Chest

HEENT:Normocephalic.MallampaticlassIwithlowerpartialinplace.
Cardiovascular:HR122,Nonotedheaves,lifts,thrillsorpulsations.PMIat5thICSMCL.
Heartsoundsareirregular.S1/S2present.NoS3/S4,rubs,gallopsormurmurs.Carotid
pulsespalpable.Nocarotid/aorticbruits.Radialpulses3+bilaterally(bounding),peripheral
pulses1+weakbilaterally.PMIispalpableat5thICS,MCL.NoJVDoredemapresentin
lowerextremities.EKG:Atrialfibrillationwithventricularrateofapproximately120.K+
4.1,Mg1.91TroponinI>0.01ng/ml
Respiratory:TachypneicRR24.SpO296%%6L/NC.Normaldepthofrespiration.No
accessorymuscleuse.Anteriorandposteriorrespirationsarediminishedbilaterallywith
rales,cracklesandrhonchipresent.Dullnesstopercussion.Tracheamidline,chestcontour
andexpansionsymmetrical.CXR:mediastinalopacityandopacityoverlyingtheleftlower
lobe;pulmonaryvascularcongestionnoted.DDimer:240ng/mlABG:pH7.24pCO255
pO260
Gastrointestinal:Abdomenappearssoft,flat,andnontender.Nodistentionobserved.
Bowelsoundspresentinall4quadrants.Noabdominalbruits.Nohepatomegaly.
Genitourinary:NoCVAtenderness.U/Oisclear,yellowand>30cc/hr.BUN24Cr0.89
ABG:pH7.24HCO316
Endocrine:Thyroidlobesareequalinsizeandconsistency,withoutbruits.Glucose86
Neuro:A&Ox4.PERRLA.Speechclear.Generalizedweaknessinlowerextremities.
Heme/Lymph/Immun:Hbg14.8Hct42.1WBC11.1Plt199PT12.9INR3.3

ASSESSMENT:(RestrictiveLungDisease)
ActualDiagnoses:SLE,Afib
ActualProblems:SLEexacerbation,Afibw/RVRsecondarytoBilateralCAP,Fever,Mixed
MetabolicandRespiratoryAcidosis,ChestPain,SOB,Fatigue
AppropriateDifferentialDiagnoses:Pneumonia,Pleurisy,PulmonaryEmbolism,Pericarditis,
Influenza,(AcuteRenalInsufficiency/FVE)
PotentialProblems:Bacteremia,sepsis,superinfections,drugtoxicity,emphysema,
pneumothorax,acuterespiratorydistressCVA,Tamponade,Arrhythmias(sinusbradycardia,
1stdegreeHBand2nddegreeMobitzIHB,supraventriculartachyarrhythmias,ventricular
arrhythmias,asystole),AcuteRenalInjury(AcuteRenalInsufficiency/FVE),Hemorrhage,
Hypotension,TRALI,FailuretoExtubate,Hyperglycemia,Anxiety
PLAN:
Patientisa46y/ofemalewithhxofSLEandAtrialFibrillationbeingevaluatedandtreatedfor
fever,SOBandfatigue.DiagnosticworkupsuggestsSLEexacerbationsecondaryto
Pneumonia.Patientsconditionisconsideredguardedandwillbeadmittedtothecardiac
telemetryforcontinuouscardiacmonitoringandtobeginempirictherapyforCAP.
Cardiovascular:AtrialFibrillationw/RVR
ConsultCardiologyforAtrialFibrillation.Maintain2largeborePIV.Metoprolol5mgIVx1
dosenowtocontrolheartrateandrhythm.GoalHR<100,holdifHR<60orSBP<90.If
patientdoesnotrespondtothebetablockerwillplantoinitiateIVCardizemandtitratetogoal.

Continuoustelemetry/BP/O2monitoring.Continuecurrentmedicaltreatmentofthepatient
pendingCardiologyevaluation/recommendation.Monitorbloodpressuretostaywithinstated
parameters.Continuetomonitorpatientforarrhythmias,tamponadeorventriculardysfunction.
Pain:TreatchestwithmorphineIVPRN.ContinuousEKGmonitoringwithnotification
parameters.EKGdailyinAMandPRNforchangestomonitorresolutionofAfib.DailyBMP,
CBC,PT/INRordered.
Respiratory:RespiratoryAcidosis/CAPPneumonia/Dyspnea/Atelectasis
PlantoadministerO2vianasalcannulaandtitrate26LtokeepSpO2>92%.Encourage
pulmonarytoiletingastolerated.Plantointubateifpatientsrespiratorystatusdeteriorates.
RepeatABG,CXRinamorifpatientsrespiratorystatuschanges.BeginEmpiricantimicrobial
therapy(Zosyn3.375mgIVq6hoursandLevaquin750mgIVoncedaily)basedonCAP.
Monitorforpendingbloodandsputumculturestoensureappropriateantibiotictherapy
coverage.
Gastrointestinal:PlantokeeppatientNPOwhilepatientshowssignsofrespiratorydistress,
increasedworkofbreathing.Startclearliquidsandadvancetoaregulardietastolerated.
Monitorbowelactivityandassessforischemicbowelorconstipation.Protonix/laxativesordered
forprophylacticmeasures.
Genitourinary:MetabolicAcidosis
0.9%NSstartedat75cc/hr.MonitorI&O.CheckBMPinam.
Neurological:Monitorpatientforneurologicalchanges.Planforq4hrneurochecks.
Endocrine:MonitorglucoselevelinamBMP.
Heme/Lymph/Immun:SLE/Fever
ConsultImmunologist/RheumatologistformanagementofSLE.HoldhomeImuran.Monitor
VS:T,HR,BPandCBCfors/sofinfection.
Prophylaxis:DVT/PUD
DVTprophylaxiscoveredbyCoumadin.FamotidineforPUDprophylaxis.
Education:Educatepatientandfamilyondiseaseprocessandtreatmentmodalities.Discuss
treatmentplananddecideonappropriatecoarsewithpatientandfamily.Continuallyeducate
patientandfamilyregardingpatientconditionandtreatmentplanaschangesinplanorpatient
statusoccur.Havedirectbutcompassionatedialoguewithfamilyandpatientregardingthe
eventofprogressionofpneumoniagivenpatientsimmunocompromisedstatesandplanto
intubateandattemptresuscitationifwarranted.Begineducationregardingdischarge
medications(BetaBlockers,etc.).Instructpatientandfamilyforsigns/symptomsthatwarrant
evaluation,whentocall911andappropriatefollowupreferrals.
Disposition:Patientisfullcode,currentlyguarded.Plantokeepontelemetryfloorunless
conditionchanges.